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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.
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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
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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
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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
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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
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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
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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
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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
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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.
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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.
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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.
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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
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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
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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
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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.
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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
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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
-
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
-
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.
-
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