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psnet.ahrq.gov/node/841306/psn-pdf
December 14, 2022 - adjust to challenges and changes while maintaining high-quality care.1
For some healthcare delivery processes … As
opposed to Safety-I, Safety-II focuses on understanding why most healthcare delivery processes are … In complex work environments, healthcare professionals adapt
standard processes and create informal … processes that allow flexibility to accomplish desired outcomes. … Work processes are typically studied and created based on
what people imagine work to be like at the
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psnet.ahrq.gov/node/43693/psn-pdf
January 20, 2015 - Effectiveness of facilitated introduction of a standard
operating procedure into routine processes in … Effectiveness of facilitated introduction of a standard operating
procedure into routine processes in … /psnet.ahrq.gov/issue/effectiveness-facilitated-introduction-standard-operating-procedure-routine-
processes … ://psnet.ahrq.gov/issue/effectiveness-facilitated-introduction-standard-operating-procedure-routine-processes … ://psnet.ahrq.gov/issue/effectiveness-facilitated-introduction-standard-operating-procedure-routine-processes
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psnet.ahrq.gov/node/47184/psn-pdf
August 08, 2018 - Delivering on the promise of CLER: a patient safety
rotation that aligns resident education with hospital
processes … Delivering on the Promise of CLER: A Patient Safety Rotation That
Aligns Resident Education With Hospital Processes … psnet.ahrq.gov/issue/delivering-promise-cler-patient-safety-rotation-aligns-resident-education-
hospital-processes … psnet.ahrq.gov/issue/delivering-promise-cler-patient-safety-rotation-aligns-resident-education-hospital-processes … psnet.ahrq.gov/issue/delivering-promise-cler-patient-safety-rotation-aligns-resident-education-hospital-processes
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/pressure_ulcer_prevention/webinars/webinar3_pu_staffroles.pdf
January 01, 2014 - • Be familiar with program goals,
care processes, and outcome data. … on:
– Pressure ulcer prevention,
– Related equipment use, and
– Related patient safety clinical processes … • Ongoing communication
and reporting
• Integrating pressure
ulcer prevention into
ongoing work processes … • Use electronic health records.
23
Examples of Ongoing Work Processes
• Conduct wound care and … Examples of Ongoing Work Processes
Ongoing Work Processes With Electronic Records
Training Staff
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psnet.ahrq.gov/issue/care-deficiencies-and-leaders-inadequate-reviews-patient-who-died-lt-col-luke-weathers-jr-va
April 10, 2024 - This analysis examines a case of communication failure during cardiac telemetry processes that resulted … November 13, 2013
Deficiencies in Inpatient Mental Health Care Coordination and Processes … July 5, 2023
Deficiencies in Quality Management Processes and Delays in the Communication
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www.ahrq.gov/sites/default/files/wysiwyg/lhs/lhs_case_studies_denver_health.pdf
April 01, 2019 - Denver Health leaders’
commitment to Lean processes has
helped to embed a systemwide
commitment to … Denver Health leaders are also thinking about data as a systemwide tool to improve processes
and patient … In addition to adopting
Toyota’s Lean processes, system leaders have embraced the Lean Kaizen approach … to look across individual reports to identify opportunities to put systemwide quality
improvement processes … Hence its commitment to Lean processes and to
giving clinicians permission to innovate and the tools
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www.ahrq.gov/practiceimprovement/delivery-initiative/casalino/paper/idkeydsrapd.html
February 01, 2014 - External incentives, information technology, and organized processes to improve health care quality for … Review: how do hospital organizational structure and processes affect quality of care? … Relationship between quality improvement processes and clinical performance. … External incentives, information technology, and organized processes to improve health care quality for … Resource sharing to support implementation of value-improving processes among small practices
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psnet.ahrq.gov/issue/decision-making-processes-used-nurses-during-intravenous-drug-preparation-and-administration
June 29, 2022 - Study
Decision-making processes used by nurses during intravenous drug preparation … Decision-making processes used by nurses during intravenous drug preparation and administration. … Decision-making processes used by nurses during intravenous drug preparation and administration.
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www.ahrq.gov/research/findings/final-reports/ptflow/section3.html
April 01, 2020 - Historically, it has been financial processes that have been measured, analyzed, and acted upon. … The first is data generation, which includes all the processes and opportunities clinicians have to enter … Data elements reflecting clinical processes may have multiple locations throughout the medical record … Pending measures continue to focus on clinical processes (time to pain management and troponin results … But CMS has signaled a willingness to look more globally at ED processes by including the throughput
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www.ahrq.gov/ncepcr/care/coordination/atlas/chapter4.html
June 01, 2014 - This information offers a view of processes of care and clinical outcomes not available within administrative … may serve as a benchmark against which to gauge care coordination processes measured at a local level … However, several studies suggest how SNA methods might provide insight into coordination processes at … This study demonstrates that applying SNA techniques to examine care coordination processes is feasible … The study by Benham-Hutchins and co-authors examined coordination processes at an even more granular
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psnet.ahrq.gov/issue/eliciting-functional-processes-apologizing-errors-health-care-developing-explanatory-model
February 01, 2023 - Commentary
Eliciting the functional processes of apologizing for errors in health … Eliciting the Functional Processes of Apologizing for Errors in Health Care: Developing an Explanatory … Eliciting the Functional Processes of Apologizing for Errors in Health Care: Developing an Explanatory
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/education/curriculum-tools/cusptoolkit/modules/assemble/assembleteam.docx
June 02, 2025 - Slide 7
SAY:
The effective group processes of CUSP teams include:
· Role clarity,
· Effective team … Bearing this in mind, the inputs, processes, and outputs the unit team encounters are interconnected … As well as the inputs, processes alter the outcome of any initiative. … Bearing in mind that unit team inputs, processes, and outcomes are interconnected, teams will be able … Execute the processes, and
4. Evaluate what was accomplished.
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www.ahrq.gov/diagnostic-safety/resources/issue-briefs/maternal-mortality-3.html
September 01, 2021 - Implementing Hospitalwide Safety Bundles
Maternal safety bundles 21 are “a structured way of improving the processes … Obstetric Hemorrhage includes 13 key elements spanning the types of equipment, checklists, personnel, and processes … Healthcare Simulation To Characterize, Design, and Change Processes
Healthcare simulation, a technique … for addressing diagnostic error in maternal health by facilitating implementation of new equipment or processes
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www.ahrq.gov/patient-safety/settings/hospital/resource/pressureulcer/tool/pu2.html
October 01, 2014 - For example, the Implementation Team may not include members with critical knowledge of care processes … If your organization already has well-established QI processes and structures, it will be beneficial … to connect the pressure ulcer improvement project with those processes. … Practice Insights
Examples of Improvement Processes
PDSA (Plan, Do, Study, Act) is an iterative … Action Steps
Set goals for improvement based on outcomes and processes.
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www.ahrq.gov/es/patient-safety/settings/hospital/resource/pressureulcer/tool/pu2.html
October 01, 2014 - For example, the Implementation Team may not include members with critical knowledge of care processes … If your organization already has well-established QI processes and structures, it will be beneficial … to connect the pressure ulcer improvement project with those processes. … Practice Insights
Examples of Improvement Processes
PDSA (Plan, Do, Study, Act) is an iterative … Action Steps
Set goals for improvement based on outcomes and processes.
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integrationacademy.ahrq.gov/sites/default/files/2021-09/ibhc_atlas_framework_and_measures.pdf
January 01, 2021 - Measurement constructs describe specific
characteristics (i.e., structures), actions (i.e., processes … Process
• Screening or other case identification processes
are used to identify and prioritize people … Structure
• Office workflows, processes, and quality
control processes that support integrated
behavioral … Process
• Consistently use specified structures, office
workflows, processes, and standards for … Process
• Collect practice-based data on key processes
(e.g., percentage of patients with a shared
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digital.ahrq.gov/health-it-tools-and-resources/workflow-assessment-health-it-toolkit/research/goetz-goldberg-d-kuzel
January 01, 2023 - employees and physicians, alternative strategies for patient care during transition, and development of new processes … implementing advanced EHR functions plan for changes in roles and responsibilities, redesign, work processes … Most practices did not proactively redesign work processes around new EHR functions. … Practices reported difficulty changing work processes to support EHR functions and difficulty customizing … Physicians and staff reported difficulty following new work processes, lack of understanding the rationale
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psnet.ahrq.gov/node/46647/psn-pdf
January 01, 2020 - How differences between manager and clinician
perceptions of safety culture impact hospital processes … How Differences Between Manager and Clinician Perceptions of
Safety Culture Impact Hospital Processes … found that in hospitals where manager and frontline perceptions of safety culture were more aligned,
processes
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integrationacademy.ahrq.gov/products/playbooks/behavioral-health-and-primary-care/implementing-plan-integrating-behavioral-health-your-ambulatory-care-setting
June 01, 2022 - to support integrated care, establishing protocols and workflows for integrated care, and developing processes … Plan
Build Patient Understanding of Setbacks and How to Deal With Them
Develop Processes … for Tracking Patients, Monitoring Outcomes, and Maintaining Engagement
Processes to track
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/qitoolkit/pdi/d4g_pdi09-postoprespfailure-bestpractices.pdf
May 17, 2016 - and
selective use of nasogastric tubes, and use short-acting
neuromuscular blockade.6,7
Best Processes … • Evaluate effectiveness of new processes, determine gaps, modify processes as needed, and
reimplement … Additional Resources
Systems/Processes
• WHO Postoperative Care
http://www.who.int/surgery/publications … Best Processes/Systems of Care
Introduction: Essential First Steps
Recommended Practice: Assess risk … failure
Educational Recommendation
Effectiveness of Action Items
Additional Resources
Systems/Processes