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ahrqpubs.ahrq.gov/research/findings/index.html
August 01, 2023 - Report
AHRQ's Making Healthcare Safer reports consolidate information for healthcare providers, health system … researchers, and government agencies about practices that can improve patient safety across the healthcare system—from
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ahrqpubs.ahrq.gov/funding/grantee-profiles/grtprofile-xiao.html
November 01, 2022 - patients, and family members—by understanding the many differing factors that affect performance of the system … categorized into six groups: medication-related tasks at home; patient and caregiver related; hospital work system … researchers who can focus on some of the most important challenges facing our Nation's health care system
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ahrqpubs.ahrq.gov/cpi/about/35th-anniversary/index.html
April 01, 2024 - AHRQ and the Department of Defense’s Military Health System jointly release TeamSTEPPS® (Team Strategies … Developed by the Agency’s Comparative Health System Performance Initiative, the compendium identifies … system characteristics, such as the number of hospitals, acute care beds, and physicians, as well as … whether a system serves children.
2018
AHRQ National Scorecard on Hospital-Acquired Conditions … Education and Research on Therapeutics (CERTs) that focused on critical issues facing the healthcare system
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ahrqpubs.ahrq.gov/diagnostic-safety/workgroup/index.html
March 01, 2024 - previously published reports from the Institute of Medicine: To Err Is Human : Building a Safer Health System … (2000) and Crossing the Quality Chasm: A New Health System for the 21st Century (2001).
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ahrqpubs.ahrq.gov/sites/default/files/wysiwyg/sops/surveys/hospital/hospitalresourcelist.pdf
January 01, 2019 - Framework for Effective Board Governance of Health System Quality
http://www.ihi.org/resources/Pages … /IHIWhitePapers/Framework-Effective-Board-Governance-
Health-System-Quality.aspx (requires free account … They also provide practical tools for trustees and the
health system leaders who support them to govern … The workshop explores how multiple weaknesses present within the hospital system can lead to
error. … • Identify system vulnerabilities that could lead to patient harm.
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ahrqpubs.ahrq.gov/ncepcr/research-transform-primary-care/transform/tpcbib/index.html
May 01, 2015 - Successful implementation requires a series of steps, including the selection of an appropriate system … The first attempt at primary care redesign in 2002 at Group Health, an integrated health care system … design principles which guided all subsequent system transformation activities. … about the effects of these system changes on patient access. … An increase in system changes was associated with a score of 5 or more on a 10-point scale for a clinic
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ahrqpubs.ahrq.gov/sites/default/files/wysiwyg/patient-safety/rev-finalreport-update-2021.pdf
January 01, 2021 - pronounced
as primary care is increasingly called to serve the key integrator role across the health system … as
part of payment and delivery system reforms. … As part of these delivery system transformations and participation in the Community-Based Care
Transitions … Sometimes they were housed
within a healthcare system department; other times, they were community-based … A system is needed to get valuable input from
outside services.
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ahrqpubs.ahrq.gov/patient-safety/settings/hospital/fall-prevention/toolkit/index.html
February 01, 2024 - Ganz, MD, PhD, VA Greater Los Angeles Healthcare System, University of California at Los Angeles, and … Corporation
Christina Huang, MPH, RAND Corporation
Debra Saliba, MD, MPH, VA Greater Los Angeles Healthcare System … Hospital and Boston University School of Public Health
Carol VanDeusen Lukas, EdD, VA Boston Healthcare System
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ahrqpubs.ahrq.gov/hai/pfp/index.html
July 01, 2020 - progress on reducing HACs and other adverse events, AHRQ is developing the AHRQ Quality and Safety Review System … This patient safety surveillance system will capture information about HACs and other adverse events
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ahrqpubs.ahrq.gov/sites/default/files/wysiwyg/research/findings/nhqrdr/2019qdr-intro-methods-cx061721.pdf
December 01, 2020 - • Behavioral Risk Factor Surveillance System data became available for the 2019
report and are … Healthcare System Landscape describes the healthcare
system, encounters, and workers; disease burden … Vital Statistics System—Mortality (NVSS-M)
• National Vital Statistics System—Natality (NVSS-N) … Crossing the Quality Chasm: A New Health System for
the 21st Century. … To Err Is Human: Building a Safer Health System.
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ahrqpubs.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/candor/module3/mod03-gap-analysis-guide.pdf
April 01, 2016 - A coding system can be used to
tally the responses to the questions. … Do staff have access to a system for reporting adverse events?
c. … Do staff have access to a system for reporting disruptive behaviors?
d. … Do staff have access to a system for reporting
adverse events? … Do staff have access to a system for reporting
disruptive behavior?
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ahrqpubs.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/perinatal-care/modules/strategies/safe-electronic/tool_safe-e-fetal-monitoring.docx
May 01, 2017 - Use a standard, three-tier system for FHR interpretation for all patients who are receiving continuous … The 2008 NICHD Workshop also proposed a three-tier system for interpreting FHR tracings. … This system is a mechanism for linking observed FHR findings on the current fetal acid-base status and … Science of Safety) (continued)
Key Perinatal Safety Elements
Examples
Use a standard, three-tier system … (continued)
Use of the standard three-tier system for interpreting and communicating FHR tracings provides
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ahrqpubs.ahrq.gov/evidencenow/projects/heart-health/about/cooperatives/southwest.html
March 01, 2021 - University of Colorado at Denver
University of New Mexico Health Sciences Center
Colorado Health Extension System … percent unspecified
Ownership
32.7 percent clinician owned
13.4 percent hospital or health system-owned … for quality measures and population management and to link practices with a central data aggregation system … Advancing Learning and Care in the Health Professions, 2016]
Influences of the Electronic Health Record System
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ahrqpubs.ahrq.gov/news/events/nac/2015-11-nac/nacmtg1115-minutes.html
May 01, 2016 - measures and data used to track and improve performance and to evaluate progress in the U.S. health system … al. for their study of the use of reference pricing in the California Public Employees’ Retirement System … She cited the difficulties that occur when transferring from system to system. Mary D. … Holve, Ph.D., of AcademyHealth, proposed that AHRQ can help create an understanding of the idea of "system … Naylor proposed creating a case study of system improvement and considering frailty/functional decline
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ahrqpubs.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/qitoolkit/combined/a1c_combo_pdifactsheet.pdf
October 01, 2015 - a patient is hospitalized and that patients experience as a result of
exposure to the health care system … These events may be preventable by changes at the system or
provider level. … Each PDI in the composite is amenable to prevention through
system-level related structures and processes
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ahrqpubs.ahrq.gov/patient-safety/settings/hospital/candor/modules/notes8.html
August 01, 2022 - Supportive management structures
Structures to “foolproof” change
Robust and transparent feedback system … Structures to “foolproof” change —These are system design elements that ensure all elements of the CANDOR … The organization needs a measurement system to track and record process improvement over time and must … The next step is to build a measurement system that includes what data will be collected over time, who … The measurement system should include information on process, outcome, and quality improvement activities
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ahrqpubs.ahrq.gov/sdoh/resources.html
April 01, 2023 - (SDOH cross-HHS coordination)
Health Resources and Services Administration’s (HRSA) Uniform Data System … AHRQ's Commitment to Meeting Unmet Needs in the Healthcare System Blog by Gopal Khanna, M.B.A., former
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ahrqpubs.ahrq.gov/funding/process/study-section/resfoci.html
October 01, 2020 - and Utilization
Cost/Finance/Markets
Qualitative & Quantitative Methods
Delivery Systems
System … Dissemination/Translation Research Findings and Methods to Reduce Medical Errors; Quality Improvement
System-Level
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ahrqpubs.ahrq.gov/sites/default/files/wysiwyg/research/findings/nhqrdr/2021qdr-final-es.pdf
January 01, 2021 - reporting data and
measures that are broadly representative of the performance of the nation’s healthcare system … of the Report
The 2021 NHQDR is organized in sections that provide an overview of the healthcare system … Overview of Disease Burden and the Healthcare System
The NHQDR provides an overview of the context … All measures reported in the 2021 NHQDR were collected in 2019 or earlier, before the rapid
health system … The report can help answer questions about which
aspects of our healthcare system exhibited the highest
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ahrqpubs.ahrq.gov/teamstepps-program/resources/additional/index.html
September 01, 2023 - This TeamSTEPPS technique, part of a proven teamwork system, promotes better communication and collaboration … This TeamSTEPPS technique, part of a proven teamwork system, is reinforced when a Spanish-speaking translator … This tool, part of the evidence-based TeamSTEPPS training system, can help staff gather information concisely