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www.ahrq.gov/sites/default/files/2025-02/nance-report.pdf
January 01, 2025 - Clearly, the legal system is designed to find and deal with only fault, though a desired
system of open … useless as a tool for repairing a flawed system. … blame is the
bedrock element of the exercise, even when the only blame belongs to the system. … A
national reporting system similar to the NASA ASRS system would be vastly more complex and
widespread … One breach,
and the system collapses from widespread lack of confidence.
2.
-
www.ahrq.gov/sites/default/files/wysiwyg/chsp/compendium/chsp-compendium-2022.xlsx
January 01, 2022 - 6 4 0 2 835 43211 203.89 0 1 1 1 1 0 0 1 0 0 0 2 1119212522 1764250985
HSI00000018 Alameda Health System … 13 12 1 2 1703 88670 70.96 0 0 0 1 0 0 0 1 1 1 1 1 3435770123 10497428933
HSI00000032 Altru Health System … 0 1 258 9394 31.58 0 0 0 1 0 0 0 1 1 557134252 1580926834
HSI00000034 Anderson Regional Health System … 28008 23.16 0 0 0 1 1 0 1 0 1 759390603 3503373819
HSI00000042 Appalachian Regional Healthcare System … 671 27263 15.93 0 0 0 1 0 0 1 1 1 1 1 1 1637764799 4320619027
HSI00000059 Atlantic General Health System
-
www.ahrq.gov/sites/default/files/wysiwyg/chsp/compendium/chsp-compendium-2022.csv
January 01, 2022 - 6 4 0 2 835 43211 203.89 0 1 1 1 1 0 0 1 0 0 0 2 1119212522 1764250985
HSI00000018 Alameda Health System … 13 12 1 2 1703 88670 70.96 0 0 0 1 0 0 0 1 1 1 1 1 3435770123 10497428933
HSI00000032 Altru Health System … 0 1 258 9394 31.58 0 0 0 1 0 0 0 1 1 557134252 1580926834
HSI00000034 Anderson Regional Health System … 28008 23.16 0 0 0 1 1 0 1 0 1 759390603 3503373819
HSI00000042 Appalachian Regional Healthcare System … 671 27263 15.93 0 0 0 1 0 0 1 1 1 1 1 1 1637764799 4320619027
HSI00000059 Atlantic General Health System
-
www.ahrq.gov/sites/default/files/2024-11/kizer-report.pdf
January 01, 2024 - overarching quality management system. … Healthcare has yet to
conceptualize a coherent vision of such a system. … for a Three Hospital Health System. … Diablo Health System
Joint Comm. on Accreditation of Healthcare Org. … Warden, Henry Ford Health System
Kenneth W.
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/ambulatory-surgery/sections/sustainability/management/overview/component-kit.docx
May 01, 2017 - Why a Frontline Management System? 2
2. Components of the Frontline Management System 3
3. … Why a Frontline Management System?
Many improvement projects fail to result in sustained gains. … in the management system became apparent. … Components of the frontline management system include—
· Daily Safety Huddles. … Summary of System Components and Expected Benefits
System Component
Expected Benefit
Daily Safety
-
www.ahrq.gov/sites/default/files/wysiwyg/chsp/data/chsp-bibliography-0802.22.pdf
August 01, 2022 - Implementation Science: A Potential Catalyst for Delivery
System Reform. … Health System
Integration With Physician Specialties Varies across Markets and System Types. … What Are the Determinants of Health System Performance? … Care Integration Within and Outside Health System Boundaries. … Health System
Characteristics, 2016. CHSP Data Brief #2.
-
www.ahrq.gov/news/newsroom/case-studies/cp31102.html
October 01, 2014 - writing and computer reminders helped to inform and inspire a growing, global open-source medical record system … As of 2011, more than 50 countries are using the system, which was first envisioned in late 2004 and … He notes, "The number of patient records supported by the system is in the millions. … national level, beginning with 250 clinics and small hospitals; 10,000 patients are already in the system … Instances of tuberculosis in homeless patients in Los Angeles are being tracked through an OpenMRS system
-
www.ahrq.gov/sites/default/files/2024-07/branscombe-report.pdf
January 01, 2024 - The system is interfaced to the
enterprise clinical information system structure so that all radiology … This system is delivered utilizing Citrix technology. … The MHINT system also plans to dovetail with the emerging national health
information system infrastructure … into
their system in text format.
2. … and current state of system
evolution.
-
www.ahrq.gov/sites/default/files/wysiwyg/research/findings/final-reports/17118-Dierks-report.pdf
June 01, 2011 - There
are three key events that prescribe state changes for the patient/system. … renders system goals unattainable. … System dynamics approach to modeling risk in complex
healthcare settings. … System Dynamics Society and Wiley-Blackwell, 2008. ISBN 978-1-935056-
01-0. … System Dynamics Society and Wiley-Blackwell, 2009. ISBN
978-1-935056-02-7.
-
www.ahrq.gov/patient-safety/reports/candor-demo-program/plan-grants/summary.html
August 01, 2022 - About half of the identified individual, team, and system failures associated with these events were … No significant implementation barriers were identified, and some sites continued to use the system. … Multicare Health System
This grant resulted in the development of criteria for Avoidable Classes of … Staff rated the new system favorably. … old system.
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www.ahrq.gov/hai/tools/perinatal-care/modules/strategies/rapid-response/tool-rapid-response-systems.html
May 01, 2017 - 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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www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/mvp/modules/cusp/science-of-safety-facguide.docx
January 01, 2017 - SAY:
A “system” is a set of parts interacting to achieve a common goal. … Slide 5
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.
2.
-
www.ahrq.gov/news/newsroom/case-studies/cp30705.html
October 01, 2014 - patient tracking software served as the model for the development of a more complex patient tracking system … HTRAK, the computer-based tracking system developed with AHRQ funding, was created by Paul Frame, MD. … Using Frame's system as a model, Bruce Block, MD, Director, Primary Care Institute, University of Pittsburgh … At the East End Community Health Center in Pittsburgh, the system was implemented to simplify documentation … The system increased insight into the complex process of health promotion as an important clinical, education
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety-2/vol1/Advances-Riley_59.pdf
April 06, 2008 - Therefore, the Act has the potential to create an event reporting system that provides
feedback for … Statements to focus efforts—will help to improve system functionality and safety. … The near
miss/hazard reports will become a uniquely rich source of system intelligence. … important to improve care, reflecting the local nature of all health
care system performance. … Medical error reporting system still a year
off.
-
www.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/system/systemredesignsafetynet/systemredesign.pptx
July 01, 2014 - PowerPoint Presentation
System Redesign for Value in
Safety-Net Hospitals and Systems:
Challenges and … Former CEO and Medical Director
Jefferson Health System/Cooper Green Hospital
Arnold Kaluzny, Ph.D. … Enhancing process improvement effectiveness: system redesign in safety-net systems. … Does our organization
have the direction and
alignment needed for
strategic system
redesign? … Does our organization have the direction and alignment needed for strategic system redesign?
-
www.ahrq.gov/sites/default/files/wysiwyg/sops/quality-patient-safety/patientsafetyculture/healthitpatientsafetyitemset-hospitals-pilottestreport.pdf
March 01, 2018 - EHR System
Training
Staff are given enough training to use their
EHR system, the training is customized … EHR System
Support and
Communication
Staff are made aware of problems with their
EHR system, asked … EHR System Training
2. EHR System Support
and Communication
50%
11
Chart 2. … EHR System Training
1. We are given enough training on how to use
our EHR system. 63%
2. … EHR System Support and Communication
1.
-
www.ahrq.gov/patient-safety/settings/labor-delivery/perinatal-care/modules/strategies/rapid-response/rapid-response-slides.html
July 01, 2023 - Identify the key safety elements of a robust rapid response system. … Slide 4: Rapid Response System
A rapid response system (RRS) includes four components: 1,2
A … A system for feedback, to help mitigate or improve response to similar situations in the future. … System is established as part of a hospital’s larger rapid response system, or is established as a separate … System feedback.
-
www.ahrq.gov/hai/cusp/modules/understand/science-safety-slides.html
July 01, 2018 - Understand the Science of Safety module of the CUSP Toolkit discusses the importance of understanding system … System-Level Factors Affect Safety 9
Slide 8. Safety is a Property of the System
Slide 9. … System-Level Factors Can Predict Performance
Slide 10. … Return to Contents
Slide 7: System-Level Factors Affect Safety 9
Image: Concentric circles … Impact of System-Level Factors
System Factor
Effect
Daily rounds with an intensivist
-
www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol4/Carayon.pdf
February 01, 2005 - In the SEIPS model of work system and patient safety, we
Advances in Patient Safety: Vol. 4
462 … measures of work system. … Work
system and patient safety. In: Luczak H, Zink KJ,
editors. … Web Survey Mailer System (WSMS1.1).
In: CQPI Technical Report Series. … Correlation and regression analyses between measures of work system
Figure 1.
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www.ahrq.gov/research/findings/nhqrdr/nhqdr16/appendixc_datasources.html
June 01, 2018 - National Tuberculosis Surveillance System (NTSS). … National Vital Statistics System—Mortality (NVSS-M). … National Vital Statistics System—Natality (NVSS-N). … Health Resources and Services Administration
Uniform Data System (UDS). … National Institutes of Health
United States Renal Data System (USRDS).