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www.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/qitoolkit/combined/d1_combo_improvementmethodsoverview.pdf
June 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/teamstepps-program/curriculum/implement/pre/ready.html
January 01, 2024 - If You're Ready, Exactly What Problem Are You Trying To Fix? … Asking key stakeholders whether they perceive the issue as a problem, how large a problem they think
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www.ahrq.gov/hai/tools/ambulatory-surgery/sections/sustainability/management/huddles-slides.html
June 01, 2017 - work by staff, the daily safety huddle, visual management, escalation, observation of safety work, problem … than one department
Slide 10: Testing and Implementation: Common Problems and Tips
Problem … #1: Huddles don’t take place when facilitator is absent or busy
Problem #2: Staff turnover has … made sustaining the huddle difficult
Problem #3: Staff seem not to see the benefit of the huddle
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol3/Sirio.pdf
June 15, 2003 - However, the issues that arise are (1) approaching patient safety as a systems
problem, and (2) overcoming … Problem-solving transforms knowledge into learning through the
creation of new standards, processes, … Implementing regionwide problem-solving
PRHI has supported regionwide problem-solving through the development … • Implementing rapid root-cause problem-solving at all levels of an
organization. … Infection control—a problem for patient
safety. N Engl J Med 2003 Feb 13;348(7):651–6.
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psnet.ahrq.gov/node/61029/psn-pdf
October 14, 2020 - A doctor gave me an inept diagnosis for a neurological
problem. I should know: I’m a neurologist. … https://psnet.ahrq.gov/issue/doctor-gave-me-inept-diagnosis-neurological-problem-i-should-know-im-
neurologist … https://psnet.ahrq.gov/issue/doctor-gave-me-inept-diagnosis-neurological-problem-i-should-know-im-neurologist … https://psnet.ahrq.gov/issue/doctor-gave-me-inept-diagnosis-neurological-problem-i-should-know-im-neurologist
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psnet.ahrq.gov/node/47861/psn-pdf
April 24, 2019 - Laney's story: the problem of delayed diagnosis of
pediatric stroke. … Laney's Story: The Problem of Delayed Diagnosis of Pediatric
Stroke. … https://psnet.ahrq.gov/issue/laneys-story-problem-delayed-diagnosis-pediatric-stroke
Rare diseases pose … https://psnet.ahrq.gov/issue/laneys-story-problem-delayed-diagnosis-pediatric-stroke
https://psnet.ahrq.gov
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www.ahrq.gov/sites/default/files/wysiwyg/antibiotic-use/long-term-care/changing-system-facilitator-guide.docx
June 01, 2021 - A problem that almost led to patient or resident harm is called a “near-miss.” … Then, the team can address the problem and takes steps to prevent it from happening again. … try to select two to five interventions to address the problem. … First, identify a problem. … The problem may also be something that frontline staff members notice as a potential problem or workaround
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/surgery/modules/implementation/imp_learn_from_defects_facnotes.docx
December 01, 2017 - Slide 3
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 4
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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digital.ahrq.gov/health-it-tools-and-resources/evaluation-resources/workflow-assessment-health-it-toolkit/all-workflow-tools/affinity-diagram
January 01, 2023 - IDENTIFY THE PROBLEM. Write out the problem so that everyone can see it. … Use brainstorming or a similar idea-generation technique to determine all aspects of the problem. … This resulting diagram will provide insight into the problem.
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/pressure_ulcer_prevention/module3/putoolkit_module3_tools.docx
June 02, 2025 - Problem:
Requires moderate to maximum assistance in moving. … Potential Problem:
Moves feebly or requires minimum assistance. … No Apparent Problem:
Moves in bed and in chair independently and has sufficient muscle strength to lift … Friction and Shear
Problem
· Skin assessment and inspection q shift.
· Minimum of 2 people + draw sheet … Potential Problem
· Keep bed linens clean, dry, and wrinkle free.
· Avoid massaging pressure points.
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www.ahrq.gov/hai/tools/ambulatory-surgery/sections/sustainability/management/overview-slides.html
June 01, 2017 - Healthcare Improvement (IHI) team studied 10 leading health care organizations that are addressing this problem … frontline managers and staff
Key elements
Daily huddles
Use of visual boards at the front line
Problem-solving … Problem-solving skills applied at appropriate level. … work by staff, the daily safety huddle, visual management, escalation, observation of safety work, problem
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www.ahrq.gov/sites/default/files/wysiwyg/sops/surveys/medical-office/diagnostic-safety-suppl-items.doc
June 02, 2025 - The amount of time for appointments is long enough to fully evaluate the patient’s presenting problem … this office have enough time to review the relevant information related to the patient’s presenting problem … The processes start when a patient seeks care for a health problem, and include:
Gathering, integrating
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psnet.ahrq.gov/node/47027/psn-pdf
June 19, 2018 - Overdiagnosis and overtreatment as a quality problem:
insights from healthcare improvement research. … Overdiagnosis and overtreatment as a quality problem: insights from healthcare improvement
research. … https://psnet.ahrq.gov/issue/overdiagnosis-and-overtreatment-quality-problem-insights-healthcare-
improvement-research … Tactics discussed include clear articulation of the problem and contributing factors, use of
theory-driven … https://psnet.ahrq.gov/issue/overdiagnosis-and-overtreatment-quality-problem-insights-healthcare-improvement-research
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www.ahrq.gov/sites/default/files/wysiwyg/patient-safety/settings/hospitals/red-toolkit/redtoolkitforms.pdf
September 01, 2012 - Question or Problem with this Packet? … Call your Discharge Educator: (555) 555-2222
Serious health problem? Call Dr. … What To Do If a Problem Arises
CALLER: Before we hang up, I want to make sure that if a medical problem … Do you know what your main problem was? … Do you know what your main problem was?
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digital.ahrq.gov/health-it-tools-and-resources/evaluation-resources/workflow-assessment-health-it-toolkit/all-workflow-tools/contingency-diagram
January 01, 2023 - When evaluating a problem, ask: What could we do to make the problem occur? … Write these adjacent to problem actions from step two using a different color.
4.
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www.ahrq.gov/es/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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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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www.ahrq.gov/sites/default/files/wysiwyg/policymakers/chipra/factsheets/fullreports/chipra-89-adhd-behavior-section-2-attach-3.pdf
June 02, 2025 - page
6 Age Info Usually in the registration of face page
7 ADHD diagnosis date Cpt or visit or
problem … page
8 ADHD-focused evidence-based
behavior therapy prescribed
Note Discussion of diagnosis or problem
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digital.ahrq.gov/principal-investigator/sockolow-paulina
January 01, 2023 - Information Needs of Homecare Nurses During Admission and Care Planning
There's a problem … 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
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psnet.ahrq.gov/node/42587/psn-pdf
September 25, 2013 - Application of an engineering problem-solving
methodology to address persistent problems in patient … Application of an engineering problem-solving methodology to address persistent
problems in patient … https://psnet.ahrq.gov/issue/application-engineering-problem-solving-methodology-address-persistent- … This case study reports on a collaboration between engineers and safety professionals to
address the problem … https://psnet.ahrq.gov/issue/application-engineering-problem-solving-methodology-address-persistent-problems-patient