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  1. www.ahrq.gov/sites/default/files/wysiwyg/sops/quality-patient-safety/patientsafetyculture/hospital/healthitwebinar/sops-hit-webcast4-yount.pdf
    June 02, 2025 - Assess how organizational culture influences health IT and patient safety 29 30 Development Process … Training (3 items) • EHR System Support and Communication (3 items) • EHR and Workflow/Work Process … EHR Workflow/Work Process 42 EHR and Workflow/Work Process Comments 43 “Need more portable workstations … EHR System Support & Communication EHR System Support & Communication Comments EHR Workflow/Work Process … EHR and Workflow/Work Process Comments EHR Overall Rating EHROverall Rating Comments Health IT Patient
  2. www.ahrq.gov/sites/default/files/wysiwyg/takeheart/training/module-7-implementation-guide.pdf
    June 02, 2025 - the process and be ready to answer questions or respond to objections. … and intervene to correct the process. … ■ Monitor AR process for behavior changes and examine user-level data. … assessing the process, if change is slow, until the changes are completed … • Incorporate care coordination into automatic referral process.
  3. www.ahrq.gov/diagnostic-safety/resources/issue-briefs/dxsafety-current-state3.html
    January 01, 2024 - They also underscored the importance of cross-cutting process improvement work in diagnostic safety. … Graber, et al. 8 Diagnostic Error Any mistake or failure in the diagnostic process leading to … . 63 The Tripartite Framework of Diagnostic Process Safety proposed to measure quality and safety of … 67,68 and the testing process. 69 3.2.3. … process.
  4. www.ahrq.gov/sites/default/files/wysiwyg/hai/tools/mrsa-2/024-ss-cusp-learning-from-defects.pptx
    April 01, 2025 - for MRSA Prevention | Surgical Services Learning From Defects 1 Educational Objectives Describe a process … (CUSP) Learning From Defects (LFD) tools and resources Work through an example of a defect and the process … MRSA Prevention | Surgical Services Learning From Defects 4 Purpose of the Learning From Defects Process … The LFD process is continuous. … The LFD process enables teams to look at the system surrounding the defects and the underlying causes
  5. www.ahrq.gov/sites/default/files/wysiwyg/hai/tools/mrsa/002-cusp-learning-defects.pptx
    October 01, 2024 - Program for MRSA Prevention | ICU & Non-ICU Learning From Defects 1 Educational Objectives Describe a process … (CUSP) Learning From Defects (LFD) tools and resources Work through an example of a defect and the process … | 8 AHRQ Safety Program for MRSA Prevention | ICU & Non-ICU Learning From Defects LFD Process: What … | 12 AHRQ Safety Program for MRSA Prevention | ICU & Non-ICU Learning From Defects LFD Process: Why … The LFD process is continuous.
  6. www.ahrq.gov/sites/default/files/2024-01/cohen-report.pdf
    January 01, 2024 - It is the first study to apply ST-PRA to the community pharmacy dispensing process. … and Control System Map The research team created a process and control map of the dispensing process … This more closely models the process in one of the two participating chain pharmacies. … The essence of business process re-engineering. … Process modeling. Commun ACM. 1992;35(9):75-90. 82 Oakland JS.
  7. www.ahrq.gov/sites/default/files/wysiwyg/pqmp/toolkits/sca-key-drive-diagram.pdf
    June 02, 2025 - Process to support massed appointments. Holiday or birthday cards with t c d reminders. … Standardized process for obtaining prior authorizations Preventative care patient education Standardized … Process for clinic to create notarized care plans to identify authorized caregivers. … Develop process and data collection tools. … Reliable process for obtaining medications.
  8. www.ahrq.gov/sites/default/files/2024-07/stock-easton-report.pdf
    January 01, 2024 - practices process design. … if the process was in control. … that process in control for the same period. … part of process improvement. … • Stakeholder ownership in the process and development is critical.
  9. www.ahrq.gov/sites/default/files/2025-02/silver2-report.pdf
    January 01, 2025 - The risk model was developed using process mapping, input from home health subject matter experts (SME … reliability ST-PRA risk modeling – Process mapping – Process mapping – Reliability engineering, human … The review process considered: 1. Time (in days) from start of care to hospitalization 2. … Agencies noted the value of this process in highlighting recognized issues. … The Behavior-Based Safety Process (2nd Ed.).
  10. www.ahrq.gov/sites/default/files/wysiwyg/pqmp/toolkits/pqmp-data-process-flow.pdf
    June 02, 2025 - Step 3: Practice reviews key practice-wide process measure performance. … Step 3: Practice reviews key practice- wide process measure performance Step 2: Chart review of at least … Step 3: Practice reviews key practice- wide process measure performance. … This process flow map assumes that the sponsor of this Phase 2 “deep dive” effort provides quality
  11. www.ahrq.gov/diagnostic-safety/resources/issue-briefs/dxsafety-terminology3.html
    April 01, 2025 - Thus, diagnosis can refer to the label applied to a patient’s condition or the process or activities … to arrive at that label (e.g., to diagnose, diagnosing, diagnostic process). 5 As these perspectives … illustrate, the term can be either a noun or verb, a conclusion or process. 6   Judgments about the … correctness or adequacy of a diagnostic label or process can also change over time as science informs
  12. www.ahrq.gov/diagnostic-safety/resources/issue-briefs/dxsafety-cognitive-load3.html
    May 01, 2024 - between increasing cognitive load and decreasing diagnostic accuracy are cognitive overload and dual-process … occurs when working memory becomes overly burdened, leading to a decreased ability to learn, accurately process … interrupted or asked to perform two simultaneous tasks extraneous to their primary task, they have to process … Cognitive Load and Dual-Process Thinking Cognitive load also directly impacts dual-process thinking. … Cognitive load directly affects clinicians’ ability to engage in dual-process thinking.
  13. www.ahrq.gov/teamstepps-program/curriculum/implement/pre/measure.html
    January 01, 2024 - Measurement is the process of classifying based on the characteristics of an object or action. … Continued implementation and sustainability: Measures are used to assess process and outcome changes … Other process measures may make a stronger case for TeamSTEPPS than any of the measures noted above. … : (after the trainings) What process and outcome measures would be of most concern? … when gathering data on these process and outcome measures?
  14. www.ahrq.gov/sites/default/files/2024-09/khare-report.pdf
    January 01, 2024 - ED) operational and quality management characteristics and to identify and implement generalizable process … An FMECA elicits information about any failures for each step in a process including the underlying … The scope of the FMECA was the process of ED management of patients with STEMI. … Six steps of the FMECA process were completed. … Additional process improvements included developing a standard process for changing intravenous lines
  15. www.ahrq.gov/sites/default/files/wysiwyg/teamstepps-program/dx-improvement/module5-situation-monitoring.pptx
    January 10, 2022 - (TeamSTEPPS for Office-Based Care: Situation Monitoring, 2015) 5 Slide Process of actively scanning … Situation monitoring is important across each step of the diagnostic process.   … One way to address the breakdowns and improve team effectiveness is to use a cross-monitoring process … The STEP process is a mnemonic tool that can help team members monitor the situation and the overall … The STEP process involves ongoing monitoring of the:   Status of the patient: What are the patient’s
  16. www.ahrq.gov/sites/default/files/wysiwyg/teamstepps-program/dx-improvement/module5-presenters-notes.pdf
    January 10, 2022 - Situation monitoring is important across each step of the diagnostic process. … [Image source: National Academy of Medicine conceptualization of the diagnostic process, 2015.] … Slide 9 STEP Process for Situation Monitoring One approach that helps with situation monitoring … is to use the STEP process. … The STEP process involves ongoing monitoring of the: • Status of the patient: What are the patient’s
  17. www.ahrq.gov/sites/default/files/wysiwyg/teamstepps-program/dx-improvement/module2-presenters-notes.pdf
    January 12, 2022 - Image Source: National Academy of Medicine conceptualization of the diagnostic process, 2015. … How do they contribute to the diagnostic process? Front desk personnel? Clinic nurse? … Do they know their role in the process? … Act in ways that can contribute to the diagnostic process. … • ACT: in ways that can contribute to the diagnostic process.
  18. www.ahrq.gov/sites/default/files/wysiwyg/teamstepps-program/dx-improvement/module2-team-structure.pptx
    January 12, 2022 - Image Source: National Academy of Medicine conceptualization of the diagnostic process, 2015. 5 Slide … How do they contribute to the diagnostic process? Front desk personnel? Clinic nurse? Pharmacist?   … Do they know their role in the process? … Act in ways that can contribute to the diagnostic process. … ACT: in ways that can contribute to the diagnostic process.
  19. www.ahrq.gov/sites/default/files/2024-01/hall2-report.pdf
    January 01, 2024 - Pre-implementation surveillance was conducted to establish baseline process failure rates. … These meetings served to uncover process failures and to develop measures to prevent these failures. … Multiple caregivers can be involved in the process of carrying out an order. … Not surprisingly, the process failures identified in these meetings corresponded to the gaps in care … Medication Delivery Process Overview (Site A) [large arrows represent gaps in the process] Figures 2
  20. www.ahrq.gov/sites/default/files/wysiwyg/hai/tools/clabsi-cauti-icu/central-catheter-insertion.pptx
    April 01, 2022 - 3,6 Promotes standardized supplies and insertion process Reduces potentially harmful variations in care … Build the new process, prepare staff, and conduct the pilot. … Act Adopt, abandon, or revise the process. Educate all staff on use of CVC insertion checklist. … Amount of products stocked on the unit In-unit process for ensuring supplies are available Business … hours versus after-hours and weekends process (if different) AHRQ Safety Program for ICUs: Preventing

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