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ce.effectivehealthcare.ahrq.gov/hai/tools/mvp/modules/cusp/science-of-safety-fac-guide.html
February 01, 2017 - Say:
A "system" is a set of parts interacting to achieve a common goal. … Slide 6: System Factors Impact Safety
Say:
Each level of the health care delivery system matters … Ask:
What levels can you identify within your health care delivery system? … :
Safety is the property of the system. … This means that every system is perfectly designed to achieve its end results.
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ce.effectivehealthcare.ahrq.gov/patient-safety/settings/labor-delivery/perinatal-care/modules/strategies/rapid-response/tool-rapid-response-systems.html
July 01, 2023 - A rapid response system includes four components: 1-2 A mechanism for activating a rapid response. … A system for feedback to improve future rapid responses. … A rapid response system offers a formalized way of requesting assistance. … guidance in establishing an obstetrical rapid response system at your facility. … ACTION: Determine items and measures to monitor the rapid response system.
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ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/sops/quality-patient-safety/patientsafetyculture/hospital/healthitwebinar/sops-hit-webcast4-yount.pdf
August 02, 2018 - Training (3 items)
• EHR System Support and Communication
(3 items)
• EHR and Workflow … /Work Process (3 items)
• Overall EHR System Rating (1 item)
31
Pilot Test in 44 Hospitals
32 … EHR System Training
38
39
EHR System Training Comments
“There is no formal training for the EHR … EHR system I have ever used.” … Training
EHR System Training Comments
EHR System Support & Communication
EHR System Support & Communication
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ce.effectivehealthcare.ahrq.gov/hai/cusp/clabsi-final-companion/clabsicomp5.html
January 01, 2013 - Not in a System
349
51%
In a System
88
13%
Missing
244
36%
Bed Size
… Finally, health care system was significant whereby units residing in hospitals not associated with a … system had a higher rate than units in hospitals associated with a system. …
0.0059
In a System
ref
Not in a System
0.3099
0.0059
Control …
In a System
ref
Not in a System
0.2028
<.0001
Control Status
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ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/research/findings/nhqrdr/2023nhqdr-introduction-rev.pdf
December 07, 2023 - Crossing the Quality Chasm: A New Health System for the 21st Century. … /crossing-the-quality-chasm-a-new-health-system-for-the
https://www.nap.edu/catalog/10027/crossing-the-quality-chasm-a-new-health-system-for-the … /crossing-the-quality-chasm-a-new-health-system-for-the
https://www.nap.edu/catalog/10027/crossing-the-quality-chasm-a-new-health-system-for-the … /crossing-the-quality-chasm-a-new-health-system-for-the
https://www.nap.edu/catalog/10027/crossing-the-quality-chasm-a-new-health-system-for-the … /crossing-the-quality-chasm-a-new-health-system-for-the
https://www.nap.edu/catalog/10027/crossing-the-quality-chasm-a-new-health-system-for-the
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ce.effectivehealthcare.ahrq.gov/practiceimprovement/initiatives.html
September 01, 2019 - More topics in this section
Practice Improvement
Advanced Methods in Delivery System … Research
Delivery System Research Initiative
Initiatives
System Redesign Responses … to Challenges in Safety-Net System
Practice Improvement Initiatives
The … Learning Health Systems
Becoming a learning health system is a journey characterized by strong leadership
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ce.effectivehealthcare.ahrq.gov/sites/default/files/publications/files/psml-planning-grants-final-report.pdf
May 01, 2016 - Staff rated the new system favorably. … old system. … Multicare Health System. … By implementing a patient reporting system throughout Sanford Health System—a large,
not-for-profit, … Although one-third of respondents indicated the new system improved on the previous system,
two-thirds
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ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/chsp/reports/chsp-issue-brief-3.pdf
January 01, 2019 - Third Annual CHSP CoE Workshop
ISSUE BRIEF Third Annual Workshop
of the Comparative
Health System … ,
especially of system
performance, a central
focus of the initiative. … p
t
5
NBER studied oncology care delivery system
performance. … Whether system-affiliated hospitals have
better quality outcomes. … Measuring Health System Overall Quality with Item Response Theory Models (R-7),
A.
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ce.effectivehealthcare.ahrq.gov/takeheart/training/all-modules/index.html
December 01, 2022 - Systems Change: Understanding Your Workflow Processes to Prepare for System Change
This module describes … Building and Implementing a Successful Automatic Referral System
This module provides direction on … designing and implementing an automatic referral system. … faced with implementing an automatic referral system. … Options to Expand System Capacity and Patient Centeredness
This module explores how a hybrid CR model
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ce.effectivehealthcare.ahrq.gov/patient-safety/resources/learning-lab/transdisciplinary-learning-long-desc.html
June 01, 2020 - Lab Projects
MEDNET Resource Guide
Preventing Readmissions
Quality & Safety Review System … interoperability. 2-4 The Smart Agent system dynamically controls insulin infusions to reduce the time … Nurses found the Smart Agent system more efficient, safe, and usable than the current standard-of-care … They found the new system less demanding in terms of workload. … Operating management system for high reliability: Leadership, accountability, learning and innovation
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ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/takeheart/training/module-5-implementation-guide.pdf
February 13, 2023 - for your hospital/health
system. … with workflow are critical for building a system that they can and will use … Feedback can be used
to suggest needs for system refinements. … It is a
check to see if the system is defect free. … Lake Regional Health System.
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ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/perinatal-care/modules/strategies/rapid-response/rapidresponse_facguide.docx
May 01, 2017 - Slide 1
SAY:
In this module, we will do the following:
Define components of a rapid response system … Slide 3
SAY:
To start, we will define what makes up a rapid response system. … A rapid response system is more than a team that responds to emergencies. … a rapid response system. … A rapid response system offers a formalized way of requesting assistance.
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ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/chsp/compendium/chsp-compendium-2018-updated-2021.xlsx
January 01, 2021 - sys_ma_plan_contracts sys_ma_plan_enroll sys_apm sys_aco sys_ebpm sys_pctm
HSI00000008 Adena Health System … 94 12 51 3 3 0 1 239 10533 45.79 0 0 0 0 1 0 1 1 0 0 0 0 1 144 0 28
HSI00000010 Adventist Health System … 0214 283 85 46 63 46 4 2 0 1 496 33181 0 0 0 0 0 0 1 0 0 1 0 0 0 0 0 0 0
HSI00000018 Alameda Health System … 1 1 2 0 0 0 0 0 0 0 H3916; H3957; H5106; H5932; H9190 315859 1 1039 56 0
HSI00000029 Allina Health System … 29 1 1 0 1 276 14257 30.19 0 0 0 0 1 0 0 0 1 0 0 1 1 0 0 33
HSI00000034 Anderson Regional Health System
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ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/chsp/compendium/chsp-compendium-2018-updated-2021.csv
January 01, 2021 - sys_ma_plan_contracts sys_ma_plan_enroll sys_apm sys_aco sys_ebpm sys_pctm
HSI00000008 Adena Health System … 94 12 51 3 3 0 1 239 10533 45.79 0 0 0 0 1 0 1 1 0 0 0 0 1 144 0 28
HSI00000010 Adventist Health System … 0214 283 85 46 63 46 4 2 0 1 496 33181 0 0 0 0 0 0 1 0 0 1 0 0 0 0 0 0 0
HSI00000018 Alameda Health System … 1 1 2 0 0 0 0 0 0 0 H3916; H3957; H5106; H5932; H9190 315859 1 1039 56 0
HSI00000029 Allina Health System … 29 1 1 0 1 276 14257 30.19 0 0 0 0 1 0 0 0 1 0 0 1 1 0 0 33
HSI00000034 Anderson Regional Health System
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ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/candor/module4/module4-event-reporting-investigation-analysis.pptx
September 10, 2015 - CANDOR process.
1
Objectives
Define the key elements of a timely and comprehensive event reporting system … All of these elements support the foundation for a resilient reporting system.
… ASK:
Which of these elements are part of your current event reporting system? … System-Focused
Event Investigation and Analysis Guide3
Module 4
15
The System-Focused Event Investigation … System-Focused Event Investigation and Analysis Guide. Columbia, MD: MedStar Health.
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ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol3/Charles.pdf
January 24, 2004 - Known as the Composite Health Care System (CHCS), the DoD’s initial
health record system has made the … The Military Health System
The Military Health System (MHS) enhances our nation’s security by
providing … known as the Composite Health Care System, DoD’s initial electronic health
record. … To err
is human: building a safer health system. … Key capabilities of an electronic
health record system.
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ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/evidencenow/projects/urinary/evidencenow_it2.pdf
January 01, 2024 - with a shared quality improvement and IT infrastructure,
including a system-wide EHR (EPIC). … This project is being conducted within a networked system and has the support
of specialty and primary … Estimate the prevalence and incidence of UI in a diverse,
large, integrated health system.
2. … • Integrated IT and quality improvement structures across
the healthcare system. … to
better integrate care across the system from screening to
treatment
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ce.effectivehealthcare.ahrq.gov/diagnostic-safety/resources/issue-briefs/dxsafety-psychological-safety-4.html
September 01, 2023 - Diagnostic quality requires the active engagement of individuals and a responsive healthcare system … Professionals may develop their own system to surveil for error, although consistent and reliable feedback … can be engineered into a system and supported by system design. 22 Feedback mechanisms help physicians … , they will benefit from a more exhaustive view of broader system factors that impact safety. … Leadership committed to a culture of safety should invest resources to solve system problems that threaten
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ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/quality-resources/tools/cauti-ltc/modules/implementation/educational-bundles/indwelling-urinary-catheteruse/catheter-insertion/unlicensed-staff/scenario-instr.docx
March 01, 2017 - should not touch the catheter emptying port because it could introduce contamination into the closed system … She/he breaks the closed system while examining to check for breaks or blockages. … After seeing that the catheter system is free of blocks, she/he puts the device back together. … The closed catheter system should be maintained at all times. … Breaking the closed system can introduce contamination that could lead to an infection. AHRQ Pub.
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ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol2/Rogers.pdf
January 01, 2003 - mismatches between systems design and the structure of work
create the potential for new paths to system … , while generating ideas for
system redesign in the long term. … The system has since been cleared for use. … was not replicated on the WMA system; and (6) the WMA system would
not support report printout generation … To err
is human: building a safer health system.