-
psnet.ahrq.gov/node/836812/psn-pdf
March 30, 2022 - The concept of Root Cause Analysis and Action (RCA2) emphasizes that the
processes of analyzing and … a structured adverse event analysis tool that aims to
prospectively identify potential failures in processes … after they have occurred, FMEA focuses on engaging health
care team members in analyzing and modifying processes … to prevent medication errors, assessing blood transfusion processes to prevent morbidity and
mortality … from transfusion errors, and restructuring hospital policies and processes to prevent patient falls.4
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digital.ahrq.gov/health-it-tools-and-resources/workflow-assessment-health-it-toolkit/research/crosson-jc-etz-rs-wu-s
January 01, 2023 - Practice members reported extensive efforts to redesign work processes to take advantage of e-prescribing … considerable challenges during use of e-prescribing, however, deriving from problems coordinating new work processes … included having technical support and planning teams working with sites to understand existing work processes
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/surgery/modules/sustainability/sustainability_sustspreading_facnotes.docx
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/cahps/news-and-events/events/webinars/cahps-moving-forward-cleary-slides.pdf
March 01, 2010 - Public Health
www.ahrq.gov/cahps
Reported Patient Experiences are Related to
other Important Processes … found either positive or null
associations between patient experiences
and best practice clinical processes … • Hospitals with highest HCAHPS scores do better on
clinical processes of care measures, including … The Value and Impact of CAHPS
Reported Patient Experiences are Related to other Important Processes … and Outcomes
Patient Experienceand Patient Behavior
Patient Experience and Clinical Processes
Patient
-
www.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/qitoolkit/combined/d4i_combo_psi12-dvt-bestpractices.pdf
May 20, 2016 - tolerated.4,5 Assess for
symptoms/presence of acute DVT and provide
intervention, if appropriate.5
Best Processes … Items
• Track compliance with elements of established protocol.3,6
Evaluate effectiveness of new processes … , determine gaps, modify processes as needed, and •
reimplement.3
Develop a plan of action for … evaluate performance regularly to sustain improvements achieved.3,6
Additional Resources
Systems/Processes … Best Processes/Systems of Care
Introduction: Essential First Steps
Recommended Practice: VTE Risk Assessment
-
psnet.ahrq.gov/node/73996/psn-pdf
October 29, 2021 - It
described how strategies have changed from paternalistic to inclusive processes that consider the … lessons-learned-implementing-principled-approach-resolution-following-patient-harm
https://psnet.ahrq.gov/issue/assessing-patients-2019-experiences-medical-injury-reconciliation-processes-item-generation
-
psnet.ahrq.gov/node/72535/psn-pdf
December 02, 2020 - vaccination-campaigns
Safety professionals encourage learning from errors to enhance the safe use of new processes … for the implementation of the
COVID vaccine to help practitioners plan and activate safe vaccination processes
-
effectivehealthcare.ahrq.gov/sites/default/files/pdf/transparency-mental-health_research-protocol.pdf
September 01, 2016 - Given the
gap between observed and achievable processes and outcomes, the next critical step is the … For included studies with limited or no information on study processes and conduct in
clinicaltrials.gov … [If relevant] Your experience of study conduct and processes may be valuable to
others attempting a … Your experience of study conduct and processes may be valuable to others
attempting a similar strategy … Your experience of study conduct and processes may be valuable to others
attempting a similar strategy
-
digital.ahrq.gov/ahrq-funded-projects/care-transitions-and-teamwork-pediatric-trauma-implications-health-information
January 01, 2023 - Funding Mechanism(s)
Understanding Clinical Information Needs and Health Care Decision Making Processes … However, to develop effective solutions, it is necessary to understand the cognitive processes of those … This research conducted multiple qualitative studies to analyze and model cognitive teamwork and processes … Care transition of trauma patients: Processes with articulation work before and after handoff. … In the process, we learned how different specialties’ thinking processes and perspectives differ, and
-
digital.ahrq.gov/technology/computerized-provider-order-entry-system
January 01, 2023 - Principal Investigator
Zhang, Jiajie
Project Name
Assessing the Relationship Between Care Processes … Health Information Technology Usability
Assessing the Relationship Between Care Processes … Assessing the Relationship Between Care Processes and Clinical Decision Support for Order Entry - Final … Principal Investigator
Zhang, Jiajie
Project Name
Assessing the Relationship Between Care Processes
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effectivehealthcare.ahrq.gov/sites/default/files/investing_mittman_respondent.pdf
January 01, 2009 - www.effectivehealthcare.ahrq.gov/index.cfm)
Slide
1:
Studying
Complex
Social
Interventions
and
Processes … oriented
research
approaches
Slide
3:
Theory
in
Research
on
Social
Processes … Slide
5:
Complex
Social
Interventions
and
Processes
• Policy
and
practice
-
www.ahrq.gov/hai/cauti-tools/guides/implguide-pt2.html
October 01, 2015 - Spread
Learn From Defects
Consolidate Gains and Produce More Change
N/A
When CAUTI prevention processes … Sustainability
Part of the Daily Work
Anchor New Approaches in Culture
N/A
Evidence-based improved care processes … Start thinking early on about how your team can make CAUTI reduction processes part of your routine, … who will be accountable for sustaining the work and how they might incorporate the work into existing processes
-
www.ahrq.gov/sites/default/files/wysiwyg/professionals/education/curriculum-tools/cusptoolkit/modules/assemble/assembleteam.pptx
January 01, 2006 - for the whole team through better performance
6
Building Your CUSP Team
7
8
CUSP Teams’ Group Processes … Effective Group Processes
Norms
Role Clarity
Effective Team
Communication
Conflict Resolution
Education … unit and context
Team composition
Task design
Outputs
Change in:
Performance
Attitudes
Behaviors
Processes … Es to ensure team engagement:
Engage them in the process
Educate them about their roles
Execute the processes
-
www.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/primary-care/tpc/tpc-profile-reid.pdf
April 01, 2015 - 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.
-
www.ahrq.gov/practiceimprovement/systemdesign/leancasestudies/lean-exhibit5-14.html
November 01, 2014 - Standard work processes: Developed standard work processes for reminder calls, appointments, walk-in
-
www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol1/Cook.pdf
January 01, 2004 - exploratory, multi-method approach that could help explicate the
complex individual and organizational processes … patient safety issues that
developed in each hospital, as well as the individual and organizational processes … Given this pain, and the
overall lack of agreement as to definitions and processes for resolution, it … Thus it is imperative to develop processes that encourage health care
providers to talk about patient … These discussions, in turn, have led to new understandings of
team processes, including an appreciation
-
www.uspreventiveservicestaskforce.org/home/getfilebytoken/3UuREAobGvgLbE_FBAnrYQ
January 13, 2025 - https://www.uspreventiveservicestaskforce.org/uspstf/about-uspstf/methods-and-processes/grade-definitions … https://www.uspreventiveservicestaskforce.org/uspstf/about-uspstf/methods-and-processes/grade-definitions … https://www.uspreventiveservicestaskforce.org/uspstf/about-uspstf/methods-and-processes/grade-definitions … https://www.uspreventiveservicestaskforce.org/uspstf/about-uspstf/methods-and-processes/grade-definitions
-
effectivehealthcare.ahrq.gov/sites/default/files/use_of_handheld_mittman_respondent.pdf
January 01, 2009 - observational
and
interventional
work
o Varieties
of
decisions
and
“decision”
processes … Implementing
New
Care
Processes
• Benefit
=
f(innovative
[superior]
process … descriptive
models
of
DM
• Types
of
decisions
and
decision
processes,
-
digital.ahrq.gov/ahrq-funded-projects/development-and-assessment-artificial-intelligence-ai-enhanced-pretreatment
April 01, 2024 - by minimizing the number and severity of clinically relevant errors, and extend robust peer-review processes … treatment planning steps (e.g., defining target volumes, prescribed doses) during pretreatment peer-review processes … sharing findings to guide clinical practices and policies, this work could bring robust peer-review processes
-
psnet.ahrq.gov/node/853978/psn-pdf
September 27, 2023 - https://psnet.ahrq.gov/issue/doctors-quest-piece-together-american-health-care
Disjointed health care processes … This book shares a personal account of how broken care processes serve as
a core deterrent in one clinician