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www.ahrq.gov/sites/default/files/wysiwyg/professionals/education/curriculum-tools/cusptoolkit/modules/understand/scisafetynotes.docx
June 02, 2025 - In understanding and acknowledging this fallibility, individuals can redesign care and delivery processes … treating medicine and care delivery as a science instead of an art, providers can scrutinize their processes … Standardizing procedures, such as applying checklists and creating independent assessments for key processes … Learn from defects
This principle calls for unit teams to evaluate their processes and learn from defects … Standardize when you can
Standardize to eliminate unnecessary or repetitive steps and simplify processes
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www.ahrq.gov/hai/tools/surgery/modules/sustainability/spreading-fac-notes.html
December 01, 2017 - For example, teams often think that keeping the safe surgery bundle or processes in place is hard. … The first is to stick to the formal processes. … Continue to use the tools currently in place, such as your bundles, processes and structures. … Develop formal processes to sustain efforts, regardless of staff or management turnover. … Reinforce these processes.
When proposing a new process, make sure to set up some early wins.
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/qitoolkit/pdi/d4d_pdi05-nqi01-pneumothorax-bestpractices.pdf
May 16, 2016 - standardize practices for site identification,
marking, and procedural practice.6,7,10-12
Best Processes … • Evaluate effectiveness of new processes, determine gaps, modify processes as needed, and
reimplement … Additional Resources
Systems/Processes
• WHO Surgical Care at the District Hospital 2003, World … Best Processes/Systems of Care
Introduction: Essential First Steps
Recommended Practice: Identification … Practices
Educational Recommendation
Effectiveness of Action Items
Additional Resources
Systems/Processes
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/qitoolkit/combined/d4c_combo_psi06-pneumothorax-bestpractices.pdf
May 20, 2016 - and standardize practices for site identification,
marking, and procedural practice.6,7,10-12
Best Processes … Evaluate effectiveness of new processes, determine gaps, modify processes as needed, and
reimplement … Indicators
How To Improve Hospital Quality and Safety
4 Tool D.4c
Additional Resources
Systems/Processes … Best Processes/Systems of Care
Introduction: Essential First Steps
Recommended Practice: Identification … Practices
Educational Recommendation
Effectiveness of Action Items
Additional Resources
Systems/Processes
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/qitoolkit/combined/d4r_combo_pdi05-nqi01-pneumothorax-bestpractices.pdf
May 16, 2016 - standardize practices for site identification,
marking, and procedural practice.6,7,10-12
Best Processes … • Evaluate effectiveness of new processes, determine gaps, modify processes as needed, and
reimplement … Additional Resources
Systems/Processes
• WHO Surgical Care at the District Hospital 2003, World … Best Processes/Systems of Care
Introduction: Essential First Steps
Recommended Practice: Identification … Practices
Educational Recommendation
Effectiveness of Action Items
Additional Resources
Systems/Processes
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/surgery/modules/sustainability/sustainability_sustspreading.pptx
December 01, 2017 - For example, teams often think that keeping the safe surgery bundle or processes in place is hard. … The first is to stick to the formal processes. … Continue to use the tools currently in place, such as your bundles, processes and structures. … Develop formal processes to sustain efforts, regardless of staff or management turnover. … Reinforce these processes.
When proposing a new process, make sure to set up some early wins.
-
www.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/pressure_ulcer_prevention/module4/module4_pu-implementation_slides.pptx
June 02, 2025 - Implementation Team, the Wound Care Team, and the Unit Team
Most familiar with the program goals, care processes … thoroughly and succinctly with the least amount of time and effort.
22
Integrate Prevention Into Ongoing Processes … missing, or broken.
26
Monitor Implementation Progress
Baseline measures of pressure injury rates and processes … Tracking care processes to prevent pressure injury is a measure of implementation success and should
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/quality-resources/tools/cauti-ltc/modules/implementation/long-term-modules/module6/facilitator-notes.docx
March 01, 2017 - To summarize, sustainability occurs when processes or improved outcomes last within an organization after … Project fatigue can be prevented by making new processes routine. … SLIDE 4
SAY:
This graph shows how effective processes help ensure that after the project ends, the … practices incorporated into the mission of your organization and/or are they incorporated into existing processes … SLIDE 26
SAY:
In summary, sustainability can help organizations embed processes into their culture
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www.ahrq.gov/practiceimprovement/systemdesign/leancasestudies/lean-exhibit6-11.html
November 01, 2014 - Spaghetti mapping to show pathways of staff and patients through different processes.
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www.ahrq.gov/patient-safety/resources/learning-lab/ambulatory-pediatric-long-desc.html
January 01, 2025 - The specific aims were to: Redesign processes for adjustment of medication dosing based on clinical information … Create patient/family medication monitoring processes and communication with the clinic to prevent adverse … designed to create an entire framework for assessing parents’ knowledge and the safety of their current processes
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www.ahrq.gov/patient-safety/settings/long-term-care/resource/ontime/overview.html
November 01, 2017 - to help a multidisciplinary change team integrate the reports into the nursing home's care planning processes … The first worksheet, "Self-Assessment," is intended to help identify the current processes and structures … It is intended to help staff think about ways to transform these processes and ways to begin to use the … guide a nursing home team to integrate reports into existing workflow and make changes in prevention processes
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www.ahrq.gov/ncepcr/research-transform-primary-care/transform/profile/reid.html
October 01, 2015 - the Lean (also known as the Toyota Production System) method for implementing and standardizing care processes … in which the prototype clinic integrated process changes into its daily work and to refine the work processes … One of the outcomes of these workshops was a set of standard processes, including team role and responsibility … A second workshop was established to redesign the processes for this module.
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www.ahrq.gov/research/findings/final-reports/stpra/stprasumm.html
April 01, 2013 - validated by obtaining feedback from technical experts on the model's representation of the real system and processes … under study (e.g., the preoperative, operative, and postoperative processes for an arthroscopic knee … The proposed intervention targets two important processes of patient care: Infection control practices … control practices at ASCs be modeled after the guidelines provided to hospitals and incorporated into processes
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol2/Nieva.pdf
January 07, 2005 - transfer of research evidence into health care delivery settings
can be facilitated by the general processes … Once the appropriate knowledge and product clusters have been determined,
several processes need to … In general, such processes include priming interest, or creating
“pull” from the end users; enabling … suggest that most innovation adopters
experience similar processes: becoming aware of the innovation … The processes described in the framework will require focus and support.
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www.ahrq.gov/patient-safety/settings/labor-delivery/perinatal-care/modules/teamwork/understand-sci-fac-guide.html
July 01, 2023 - In understanding and acknowledging this fallibility, individuals can redesign care and delivery processes … treating medicine and care delivery as a science instead of an art, providers can scrutinize their processes … Standardizing procedures, such as applying checklists and creating independent assessments for key processes … Learn from defects
This principle calls for L&D unit teams to evaluate their processes and learn from … Analyzing what happened and why it happened helps the team understand the contributing factors and processes
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www.ahrq.gov/sites/default/files/wysiwyg/takeheart/training/module-5-slides.pdf
December 31, 2022 - coordination systems
Ready to Leap
5
5
Modules 5-10: Leaping
Changing and redesigning CR workflow processes … excluded from
automated referral
How Automatic Referral Addresses Process Failures
15
Problem Processes … It easily allows for
working both ends of automatic referral and care coordination processes
Eligible … interface
Without two interfacing EMRs, automatic referral can’t be implemented;
care coordination processes … Strengthening informal referral processes would be an efficient
use of resources
Automatic Referral
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www.ahrq.gov/patient-safety/settings/hospital/resource/pressureulcer/tool/pukey.html
October 01, 2014 - Knowledge
Tools 2G-2H
Building an Implementation Team
Tool 2A
Assessing Quality Improvement Processes … Edu c ating Staff
Measuring Prevalence and Incidence Rates
Tool 5A
Measuring Key Processes
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www.ahrq.gov/es/patient-safety/settings/hospital/resource/pressureulcer/tool/pukey.html
October 01, 2014 - Knowledge
Tools 2G-2H
Building an Implementation Team
Tool 2A
Assessing Quality Improvement Processes … Edu c ating Staff
Measuring Prevalence and Incidence Rates
Tool 5A
Measuring Key Processes
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www.ahrq.gov/diagnostic-safety/resources/issue-briefs/dxsafety-current-state3.html
January 01, 2024 - emphasized work-system-related topics, such as streamlining workflows and enhancing reliability of processes … Cognitive Processes
Cognitive processes encompass mental processes related to medical decision making … Many challenges and opportunities arise with use of AI for real-world clinical diagnosis, where processes … Patient-Centered Communication and Processes
Awareness has grown of the impact patient engagement … Efforts to make diagnostic processes safer include enhancing interprofessional communication and teamwork
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www.ahrq.gov/patient-safety/settings/hospital/candor/modules.html
August 01, 2022 - This activates initiation of coordinated post-event processes, as depicted below and described in the … Review and revise the organization’s current processes to align with the CANDOR process.