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  1. monahrq.ahrq.gov/patient-safety/reports/advancing/index.html
    July 01, 2022 - The IOM noted that many of the errors in health care result from a culture and system that is fragmented … Today, while progress has been made, it has not spread evenly throughout the Nation's health care system … AHRQ and the Department of Defense's Military Health System jointly released a comprehensive training … The experience gained in the first decade confirms the complexity of our changing health care system. … We have learned that safety is a changing, emergent property of systems, and as our health care system
  2. monahrq.ahrq.gov/patient-safety/resources/learning-lab/building-ambulatory-long-desc.html
    April 01, 2021 - Lab Projects MEDNET Resource Guide Preventing Readmissions Quality & Safety Review System … workflow solutions for high-priority ambulatory safety issues in a publicly funded, safety-net healthcare system … Scale up effective solutions across the health system and disseminate them among safety-net health systems … perspectives on the management of abnormal subcritical tests in an urban academic safety-net health care system … Using health-system-wide data to understand hepatitis B virus prophylaxis and reactivation outcomes in
  3. monahrq.ahrq.gov/hai/cusp/modules/apply/ac-cusp.html
    December 01, 2012 - Engineering System Design to Support Behavior Choices Slide 11. … Human error is a product of both system design and behavioral choices. … System design. Behavioral choices. Learning systems. Accountability and justice. … Transparency is also vital in addressing system factors that may contribute to harm. … Explain how system design affects system results.
  4. monahrq.ahrq.gov/patient-safety/reports/national-academy-medicine.html
    February 01, 2018 - (2000) and Crossing the Quality Chasm: A New Health System for the 21st Century (2001). … Key Capabilities of an Electronic Health Record System this 2003 report sets out 8 core care delivery … Crossing the Quality Chasm: A New Health System for the 21st Century , a 2001 report, makes an urgent … call for fundamental change to the American health care system and provides overarching principles for … To Err is Human: Building A Safer Health System , this 1999/2000 report lays out a comprehensive strategy
  5. monahrq.ahrq.gov/patient-safety/settings/hospital/candor/modules/notes2.html
    August 01, 2022 - This model describes what must happen to achieve system-wide change; it also reinforces the vital role … Transparency is also vital in addressing system factors that may contribute to harm. … Human error is a product of both system design and behavioral choices. … Human error can be managed through changes in processes, procedures, training, system design, or work … System design. Behavioral choices. Learning systems. Accountability and justice.
  6. monahrq.ahrq.gov/evidencenow/tools/keydrivers/optimize-health-it.html
    November 01, 2018 - systems may require the addition of new fields and paper-based systems will need a coherent coding system … Creative use of other data sources such as a patient web portal, a laboratory system, a billing system … , or a practice’s paper-based system, may provide the best solution. … Using data that are already available in another system is often more efficient than investing time in
  7. monahrq.ahrq.gov/hai/cusp/modules/engage/index.html
    July 01, 2018 - a unit will bridge the gap between senior management and frontline providers and will facilitate a system-level … a unit will bridge the gap between senior management and frontline providers and will facilitate a system-level
  8. monahrq.ahrq.gov/sites/default/files/wysiwyg/ncepcr/tools/healthy-aging-roundtable.pdf
    September 08, 2022 - .........................................................4 Developing a Truly Person-Centered Care System … Bierman highlighted the vital need for disruption and innovation in a system not designed to foster … In a system where an estimated 25 percent of all spending is wasted, 2 opportunities exist to capture … Waste in the US Health Care System Estimated Costs and Potential for Savings. … would look like; hearing person and community voices; hearing clinician, practice, and health system
  9. monahrq.ahrq.gov/hai/cauti-tools/archived-webinars/health-literacy-slides.html
    December 01, 2017 - Barriers to Health Literacy: Increasingly Complex Health System    35 Years Ago Today Treatment … Barriers to Health Literacy Increasingly Complex Healthcare System Hospitalists, not your family … Slide 22 System Approaches: Assess All Patients for Literacy Key Strategies: Initial Patient … Social history/support system Watch for subtle clues that they don’t read well Slide 23 System … Partnering with Patients and Families to Design a Patient- and Family-Centered Health Care System: A  
  10. monahrq.ahrq.gov/sites/default/files/wysiwyg/patient-safety/rev-reportaddendum.pdf
    March 01, 2021 - routine visits; identifying and labeling these visits as postdischarge followup within the scheduling system … The system should include a timely process to obtain and review admission, discharge, and transfer notifications … Principles Into Workflow The implementation of these five principles would be facilitated by creating a system … Recognizing and acknowledging the difficulties of system change, both in terms of process and cultural … Adoption of these principles in primary care settings will be facilitated by incorporating health system
  11. monahrq.ahrq.gov/sites/default/files/wysiwyg/research/findings/nhqrdr/2022qdr-datasources.pdf
    December 01, 2022 - National HIV Surveillance System (NHSS) Sponsor U.S. … National Tuberculosis Surveillance System (NTSS) Sponsor U.S. … Resource and Patient Management System (RPMS) and National Patient Information Reporting System (NPIRS … System. … surveillance system designed to replace the Medicare Patient Safety Monitoring System (MPSMS) for measurement
  12. monahrq.ahrq.gov/healthsystemsresearch/virtual-roundtable-discussion/index.html
    March 01, 2023 - This invitation-only, interactive roundtable discussion convened health system leaders and public health … this meeting will form the basis for further discussion among Federal stakeholders that work on health system
  13. monahrq.ahrq.gov/funding/grant-mgmt/index.html
    December 01, 2022 - Inquiries should be directed to: ONE-DHHS—the PMS Help Desk, providing assistance to all system users … Submit the Federal Financial Report (SF 425) electronically via the Payment Management System (PMS). … AHRQ requires the electronic submission, via the Payment Management System (PMS), of a financial report … elements of the final Federal Financial Report (FFR; SF-425) submitted via the Payment Management System … An online system called "iEdison" has been developed to allow grantees to fulfill this requirement.
  14. monahrq.ahrq.gov/patient-safety/resources/learning-lab/acute-care-threats-long-desc.html
    February 01, 2024 - Lab Projects MEDNET Resource Guide Preventing Readmissions Quality & Safety Review System … and guide the design, development, testing, implementation, and evaluation of interventions targeting system … But this project highlights the complex sociotechnical system within which individual clinicians operate … novel approaches to the detection of diagnostic error within the context of a complex social-technical system … The lab is ideally placed to capture lessons learned from the resulting work system reorganization before
  15. monahrq.ahrq.gov/cpi/about/20timeline/testimonials.html
    January 01, 2020 - Associate Chief of Staff of Research at the Department of Veterans Affairs Salt Lake City Health Care System … , discusses three of AHRQ’s contributions to the U.S. healthcare system: creating research and evidence … raising awareness of patient safety issues, but also on developing toolkits that improve the healthcare system … Embí, M.D., President of the Regenstrief Institute, describes how the American healthcare system has
  16. Facapplycusp (doc file)

    monahrq.ahrq.gov/sites/default/files/wysiwyg/professionals/education/curriculum-tools/cusptoolkit/modules/apply/facapplycusp.docx
    September 04, 2012 - Slide 2 SAY: The term “Just Culture” refers to a safety-supportive system of shared accountability … Slide 4 SAY: A Just Culture environment allows the review of both system design and an employee's … Human error is a product of both system design and behavioral choices. … System design; 3. Behavioral choices; 4. Learning systems; and 5. Accountability and justice. … Transparency is also vital in addressing system factors that may contribute to harm.
  17. monahrq.ahrq.gov/data/resources/index.html
    April 28, 2024 - The Compendium database includes: System identification number (a unique number assigned by AHRQ), name … Indicators of which data source identified the health system and health system identification numbers … Total counts of system hospitals, physician groups, physicians, primary care physicians, extent to which
  18. monahrq.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/perinatal-care/modules/strategies/rapid-response/rapidresponse.pptx
    October 01, 2017 - The training materials and tools in this bundle review the key elements of a rapid response system within … A rapid response system (RRS) includes four components:1,2 A mechanism for activating a clinical team … System is established as part of a hospital’s larger rapid response system, or is established as a separate … Rapid Response Perinatal Safety 18 Unit Next Steps Decide whether to select the rapid response system … Support implementation of unit rapid response system through: Staff training/communication Simulation
  19. monahrq.ahrq.gov/teamstepps/rrs/rrsacknowledgments.html
    October 01, 2014 - Acknowledgments TeamSTEPPS Rapid Response Systems Module TeamSTEPPS is a teamwork system … contributed a great deal of their time and expertise to the development of the TeamSTEPPS Rapid Response System
  20. monahrq.ahrq.gov/challenges/data-visualization/index.html
    February 01, 2024 - competition: Kaiser Foundation Research Institute  proposes to work with a large community-based health system … ValleyWise Health System  proposes to create a data visualization tool for depression screening and care … participating organizations will develop the visualization and deploy it across a participating health system … Plan for access to and use of healthcare system electronic medical record and integration of the tool … Understands that AHRQ will not select a winner that is named on the Excluded Parties List System (EPLS

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