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www.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 … 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 Approaches: Assess All Patients for Literacy
Red Flags: Patients with literacy issues may:
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/long-term-care/resources/ontime/prevhosp/prevhospitalvisits-funcspecs_0.pdf
August 01, 2017 - design in order to add the On-Time modules to their system. … Facility Name System IF the report is generated for a facility versus a single nursing unit,
display … Footer Date Source Valid Input and Display
Print Date System Display month/date/year the report was … • A resident may have multiple transfers to the ED on the same date, so the system must assign
a … The system is the data source for all elements and computes all
information that displays.
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www.ahrq.gov/hai/tools/surgery/modules/on-boarding/science-of-safety-slides.html
December 01, 2017 - Every system is perfectly designed to achieve its results. … determines performance, and safety is the property of the system. … Use strategies to improve system performance. … An arrow points through the system factors into the funnel. … Slide 10: Safety Is a Property of the System
This video illustrates using system lenses in action
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety-2/vol3/Advances-Singh-R_68.pdf
April 20, 2008 - It dedicates a separate page to
each of 18 entities/interactions within the system. … Crossing the quality chasm: A new health system for
the 21st century. … To err is
human: Building a safer health system. … Practice-based
failure modes and effects analysis for system
enhancement. … In: Crossing
the quality chasm: A new health system for the 21st
century.
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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-Browne_5.pdf
January 20, 2008 - Left unchanged, a system can only be
expected to continue to achieve the same results. … with the cardiorespiratory monitoring system. … System changes to improve patient safety.
Br Med J 2000; 320: 771-773.
11. Shappell SA. … The human factors analysis and
classification system – HFACS. U.S. … The Veterans
Affairs root cause analysis system in action.
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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-Emanuel-Berwick_110.pdf
July 02, 2008 - of as a
feature of the system. … Patient safety must be an
attribute of the health care system. … on other places in the system. … So, when designing a system, improving a
system, analyzing an adverse event, researching an issue, or … Work system
design for patient safety: The SEIPS model.
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www.ahrq.gov/research/findings/final-reports/iomracereport/reldataapa.html
May 01, 2018 - Improving Data Collection across the Health Care System
6. Implementation
A. … Assistant Secretary for Planning and Evaluation, HHS
BRFSS
Behavioral Risk Factor Surveillance System … for Standardization
LEP
Limited English Proficiency
MEDS
Medi-Cal Eligibility Data System … Council
NSDUH
National Survey on Drug Use and Health
NVSS
National Vital Statistics System … Formerly known as the Utilization Review Accreditation Commission
WCRS
Wisconsin Cancer Reporting System
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www.ahrq.gov/sites/default/files/publications/files/execsumm-lean-redesign.pdf
March 01, 2017 - PAMF is a large, not-for-
profit, ambulatory care system with clinics very similar to those found in … Contextual frameworks for research on the implementation of
complex system interventions. … Slides available at http://www.ahrq.gov/professionals/systems/system/delivery-system-
initiative/index.html … Scaling Lean in primary care: impacts on system
performance. … /delivery-system-initiative/index.html
http://www.ahrq.gov/professionals/systems/system/delivery-system-initiative
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www.ahrq.gov/sites/default/files/wysiwyg/ncepcr/tools/PCMH/using-health-it-to-support-qi.pdf
March 01, 2015 - Foresight’s transition from a paper-based
health records system to an electronic system occurred in … For a few years, the practice had a hybrid electronic–paper system. … An Academic Health System: University of Missouri
Health System (UMHS), Columbia, Missouri
The UMHS … The EHR makes it easy to message other providers in the system. … or hospital
system.
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www.ahrq.gov/sites/default/files/wysiwyg/pqmp/measures/chronic/chipra-141-section-2-tech-specs.pdf
December 01, 2012 - To assign involved body system(s) and progressive status, Seattle Children's Research Institute … conditions defined by diagnostic codes outlined in the Chronic Illness and Disability
Payment System … References:
Chronic Illness and Disability Payment System (CDPS), University of California, San … The final result is a dataset where identifications of body system, progressivity, and malignancy … Future revisions to the ICD-9 classification system
may result in the need for revisions to this
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/surgery/modules/sustainability/sustainability_learn_from_defects_facnotes.docx
December 01, 2017 - It doesn’t protect future patients or strengthen the system. … Slide 6
Individual Mistake or System Failure? … SAY:
Is a defect an individual mistake or a system failing? … We wind up building workarounds to overcome poor system problems. … SAY:
Many small defects often contribute to big system flaws.
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www.ahrq.gov/hai/tools/surgery/modules/sustainability/learn-from-defects-fac-notes.html
December 01, 2017 - It doesn’t protect future patients or strengthen the system. … And you should find that staff recognize these system improvements. … Slide 7: Individual Mistake or System Failure? … Say:
Is a defect an individual mistake or a system failing? … Say:
Many small defects often contribute to big system flaws.
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www.ahrq.gov/sites/default/files/wysiwyg/sops/quality-patient-safety/patientsafetyculture/healthitresourcelist.pdf
January 01, 2019 - EHR System Training ................................................................................. … EHR System Training
1. … EHR System Support and Communication
1. … EHR System Training
Composite 2. … Issues
EHR and Workflow/Work Process
Overall EHR System Ratings
General Resources
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www.ahrq.gov/news/newsroom/case-studies/201411.html
August 01, 2014 - Using the survey to monitor its performance, Mercy Health saw steady system-wide improvement in its overall … The intensity of that system-wide effort led to a slight drop in its goal of creating and sustaining … recent years, the survey findings have helped Mercy Health revamp its patient safety event reporting system … activities at Mercy Health, including the following:
Implementing SAFECARE, an event reporting system … Partnering with the Institute for Healthcare Improvement's "Safety Across the System" in an effort to
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www.ahrq.gov/funding/process/study-section/peerdesc.html
July 01, 2017 - within organizations and/or systems of care, and the organization and functioning of the health care system … This focus encompasses system-level and market-level questions as well as investigations of the behavior … quantitative, analytical approach to the subject matter, including behavioral modeling of health care system … safety; research focused on healthcare associated infections; and examining effective ways to make system-level … Applications containing behavioral modeling of health care delivery system processes; qualitative examinations
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/perinatal-care/modules/teamwork/understand/understand-facilitator-guide.pdf
May 01, 2017 - Safety module
of the AHRQ Safety Program for Perinatal
Care discusses the importance of
understanding system … will—
• Describe the historical and
contemporary context of the Science of
Safety,
• Explain how system … design affects
system results,
• List the principles of safe design and
identify how they apply to … Slide 2
SAY:
Examples of the effect of defects and errors in
the U.S. health care system are illustrated … Being cognizant
of the system design and how it
contributes to the results that it delivers
will help
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/surgery/modules/onboarding/onboarding_scienceofsafety_training.pptx
December 01, 2017 - The discussion will include the importance of understanding system design, the principles of safe design … Today we will discuss how to use system lenses to uncover hazards and defects with the use of PSSA. … determines performance, and safety is the property of the system
Use strategies to improve system performance … It shows the continuum of system factors that can influence health care delivery and the occurrence of … You and your team will find a system that works best for you.
23
What’s Next?
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www.ahrq.gov/hai/tools/surgery/modules/implementation/learn-from-defects-slides.html
December 01, 2017 - Slide 7: Individual Mistake or System Failing? … “Rather than being the main instigators of an accident, operators tend to be the inheritors of SYSTEM … Contributing factors from all levels of your health care system impact care delivery and, ultimately, … Develop a “system perspective” to see the hidden factors that led to the event. … Each hole represents a system failure; together the holes ultimately allow a patient to suffer.
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www.ahrq.gov/ncepcr/care/coordination/atlas/chapter6i.html
June 01, 2014 - Table
Measurement Perspective:
Patient/Family
Health Care
Professional(s)
System … The model identifies 6 elements of a delivery system that lead to improved care for the chronically ill … , including: (1) organization of care within the health system, (2) clinical information systems, (3) … decision support, (4) delivery system design, (5) self-management support, and (6) community resources … Date: Measure published in 2004. 1
Perspective: System Representative(s)
Measure Item Mapping:
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www.ahrq.gov/ncepcr/care/coordination/atlas/chapter6o.html
June 01, 2014 - Table
Measurement Perspective:
Patient/Family
Health Care
Professional(s)
System … Construct validity of the measure was also verified. 1
Link to Outcomes or Health System Characteristics … Table
Measurement Perspective:
Patient/Family
Health Care
Professional(s)
System … This instrument was developed by The Center for Studying Health System Change (HSC). … Health System Change (HSC) Web Site. Available at: http://www.hschange.org/CONTENT/1091/ .