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psnet.ahrq.gov/node/72673/psn-pdf
January 27, 2021 - Implicit bias in stroke care: a recurring old problem in the
rising incidence of young stroke. … Implicit bias in stroke care: A recurring old problem in the rising incidence of
young stroke. … https://psnet.ahrq.gov/issue/implicit-bias-stroke-care-recurring-old-problem-rising-incidence-young-stroke … https://psnet.ahrq.gov/issue/implicit-bias-stroke-care-recurring-old-problem-rising-incidence-young-stroke
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/qitoolkit/pdi/d1_pdi_improvementmethodsoverview.pptx
June 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.pptx
June 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
-
www.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/qitoolkit/pdi/d1_pdi_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
-
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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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/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/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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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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psnet.ahrq.gov/node/44427/psn-pdf
October 13, 2015 - Problem list completeness in electronic health records: a
multi-site study and assessment of success … Problem list completeness in electronic health records: A multi-
site study and assessment of success … https://psnet.ahrq.gov/issue/problem-list-completeness-electronic-health-records-multi-site-study-and … -
assessment-success
A patient problem list is a catalog of all health issues affecting a patient. … However, to serve these purposes, the problem list must be
accurate and complete.
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www.ahrq.gov/sites/default/files/wysiwyg/antibiotic-use/long-term-care/changing-system-slides.pptx
June 01, 2021 - intervention is effective.
2
Changing the System
2
View Potential Harms as Opportunities1
Reframe a problem … or error as an opportunity to prevent the same problem from occurring again
System design
Can result … 17
Changing the System
17
Review
Consider system/active failures which may have led to the problem … Apply 4 moments
Identify a problem
Learn from the problem to improve the system
18
Changing the System
-
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/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/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/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/ambulatory-surgery/sections/sustainability/management/observation/observation.pptx
May 01, 2017 - Supervisor can report on gaps in daily huddle and use problem-solving methods to reduce the gaps. … jpeg
image1.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
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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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www.ahrq.gov/sites/default/files/wysiwyg/ncepcr/tools/PCMH/pcpf-module-21-leadership.pdf
September 01, 2015 - This involves the leader identifying
the problem, identifying the solution to the problem, and then … Examples include, “What is your ideal solution to this problem?” … problem and determine whether it is truly a “problem” or merely a misinterpretation
of a situation … Think of a problem you have tried (and failed) to fix multiple times. … leaders then must gather information on the problem.
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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