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  1. www.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.
  2. www.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
  3. www.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
  4. www.monahrq.ahrq.gov/sites/default/files/wysiwyg/evidencenow/tools-and-materials/ehr-reports.pdf
    March 01, 2016 - Producing Accurate Clinical Quality Reports for Population Health: A Delivery System-Oriented Approach … Report Validation Producing Accurate Clinical Quality Reports for Population Health: A Delivery System-Oriented … , use specific features of the system, and document patient care using structured data.3,4 The early … As shown in Figure 1, to generate reports using an internal process, the delivery system must have … In addition to creating queries to monitor care gaps, the delivery system may wish to develop reports
  5. www.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  
  6. www.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
  7. www.monahrq.ahrq.gov/patient-safety/settings/labor-delivery/perinatal-care/modules/teamwork/understand-sci-fac-guide.html
    July 01, 2023 - Explain how system design affects system results. … Being cognizant of the system design and how it contributes to the results that it delivers will help … Slide 6: System-Level Factors Affect Safety Say: As the illustration shows, at any given time, … there are several system factors that simultaneously influence unit culture and patient safety. … Slide 7: System-Level Factors Can Predict Performance Say: When nurse-to-patient ratios exceed
  8. www.monahrq.ahrq.gov/sites/default/files/wysiwyg/sops/quality-patient-safety/patientsafetyculture/hospital/healthitwebinar/sops-hit-webcast-keytakeaways.pdf
    August 01, 2018 - hospital providers and staff to address the following topic areas: Electronic Health Record (EHR) System … Training EHR System Support & Communication EHR Patient Safety & Quality Issues EHR & Workflow/Work … Process Overall EHR System Rating 2 What did we learn from the pilot test? … In the past 3 months... 66% discovered incomplete information in their EHR system 61% discovered
  9. www.monahrq.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/perinatal-care/modules/teamwork/understand/understand-science-safety.pptx
    May 01, 2017 - AHRQ Safety Program for Perinatal Care Science of Safety Health Care Defects In the U.S. health care system … patient 4 AHRQ Safety Program for Perinatal Care Science of Safety 4 The Science of Safety Every system … Factors Affect Safety6 6 AHRQ Safety Program for Perinatal Care Science of Safety 6 System-Level … Factors Can Predict Performance Examples of Impact of System-Level Factors System Factor Effect Nurse-to-patient … To err is human: building a safer health system. Washington, DC: National Academy Press; 1999.
  10. www.monahrq.ahrq.gov/patient-safety/settings/labor-delivery/perinatal-care/modules/teamwork/understand-sci-slides.html
    July 01, 2023 - Explain how system design affects system results. … Slide 5: The Science of Safety Every system is perfectly designed to achieve its end results. … Slide 6: System-Level Factors Affect Safety 6 Image: Concentric circles show the layered impact of … Slide 7: System-Level Factors Can Predict Performance Examples of Impact of System-Level Factors … To err is human: building a safer health system. Washington, DC: National Academy Press; 1999.
  11. www.monahrq.ahrq.gov/sites/default/files/wysiwyg/policymakers/chipra/demoeval/what-we-learned/pa-specialinnovation.pdf
    August 01, 2015 - Sites gradually transitioned to the new system between 2011 and 2013, so the two different methods … Providers reported that the fully- automated electronic system minimized the amount of time that they … The electronic system also supports billing during the screening encounter and the ability to review … Families reported that the electronic system was easy to use and it allowed them to feel more involved … with 12 practices before going system- wide.
  12. Table 7B.1 (pdf file)

    www.monahrq.ahrq.gov/sites/default/files/wysiwyg/pqmp/measures/acute/chipra-143-section-7b.pdf
    February 02, 2018 - GAPPS study analytic sample (n= 3,442) Chronic Condition Indicators n (%) AE rate P-Value 0 body system … 1,935 (56.2%) 0.07 Reference 1 body system 1,067 (31.0%) 0.12 <0.001 2 body systems 315 (9.2%) 0.25 … analytic sample (n= 3,442) Chronic Condition Indicators (CCI) RRa (95% CIb) P-Value 0 body system
  13. www.monahrq.ahrq.gov/teamstepps/rrs/videos/index.html
    July 01, 2018 - module will provide insight into the core concepts of teamwork as they are applied to the rapid response system … DoD) and the Agency for Healthcare Research and Quality (AHRQ) have developed TeamSTEPPS, a teamwork system
  14. www.monahrq.ahrq.gov/sites/default/files/wysiwyg/research/findings/factsheets/translating/action3/ACTION4-profiles.pdf
    February 08, 2021 - Nemours Children’s Health System Vanderbilt University Medical Center Research Organizations … The Health Care System Research Network, together with long-time learning health system partners (Intermountain … , delivery system science, quality improvement Additional Information: Our network brings together … Delivery system research needs to guide and inform efforts. … Systems Duke University Health System Oregon Health System Parkland Health and Hospital System
  15. www.monahrq.ahrq.gov/news/events/nac/2017-11-nac/nacmtg1117-minutes.html
    February 01, 2018 - Khanna stated that the overall system will become more rather than less complex over time. … AHRQ must advance its support for delivery-system research. … Funding the Next Generation of Learning-Health-System Researchers. … Its data helped to inform creation of the new ICD-10 coding system, transitioning from ICD-9. … Dittus encouraged the project to consider adding metrics for system performance. Ms.
  16. www.monahrq.ahrq.gov/sites/default/files/wysiwyg/pqmp/measures/duration/chipra-157-icd-9-codes.pdf
    August 10, 2018 - septal closure 746 Other congenital anomalies of heart 747 Other congenital anomalies of circulatory system … Anencephalus & similar anomalies 741 Spina bifida 742 Other congenital anomalies of the nervous system … 748 Congenital anomalies of respiratory system 749 Cleft palate & cleft lip 750 Other congenital … anomalies of upper alimentary tract 751 Other congenital anomalies of digestive system 756 Other congenital … anomalies of musculoskeletal system 758 Chromosomal anomalies 759 Other unspecified congenital anomalies
  17. www.monahrq.ahrq.gov/sites/default/files/wysiwyg/pqmp/measures/duration/chipra-155-section-7-b-icd-9-codes.pdf
    September 12, 2018 - septal closure 746 Other congenital anomalies of heart 747 Other congenital anomalies of circulatory system … Anencephalus & similar anomalies 741 Spina bifida 742 Other congenital anomalies of the nervous system … 748 Congenital anomalies of respiratory system 749 Cleft palate & cleft lip 750 Other congenital … anomalies of upper alimentary tract 751 Other congenital anomalies of digestive system 756 Other … congenital anomalies of musculoskeletal system 758 Chromosomal anomalies 759 Other unspecified congenital
  18. www.monahrq.ahrq.gov/sites/default/files/wysiwyg/pqmp/measures/duration/chipra-153-section-7b-table-4.pdf
    June 01, 2018 - septal closure 746 Other congenital anomalies of heart 747 Other congenital anomalies of circulatory system … Anencephalus & similar anomalies 741 Spina bifida 742 Other congenital anomalies of the nervous system … 748 Congenital anomalies of respiratory system 749 Cleft palate & cleft lip 750 Other congenital … anomalies of upper alimentary tract 751 Other congenital anomalies of digestive system 756 Other … congenital anomalies of musculoskeletal system 758 Chromosomal anomalies 759 Other unspecified congenital
  19. www.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.
  20. www.monahrq.ahrq.gov/sites/default/files/wysiwyg/sops/events/webinar/nh-workplace-safety-ginsberg.pdf
    January 01, 2015 - ► The lead Federal agency charged with improving the safety and quality of America’s healthcare system … Generate measures and data to track and improve performance and evaluate progress of the US health care system … improvement to all settings • Prevent HAIs, reduce antibiotic resistance • Build capacity in the health care system … Determines behaviors that are: Rewarded Supported Expected Accepted Exists at multiple levels: System … Learning System AHRQ’s Surveys on Patient Safety Culture™(SOPS®) Program Agency for Healthcare Research

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