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  1. www.monahrq.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/ambulatory-surgery/sections/sustainability/management/observation/observation-facnotes.docx
    May 01, 2017 - SLIDE 2 Title: A Frontline Management System To Promote Safety Standard Work SAY: Regular observation … of safety standard work forms a key connection in our frontline management system between the other … Model for Improvement to Observation SAY: As with the other elements in the frontline management system … and Integration SAY: Observation of standard work has a natural linkage to another element of our system—the
  2. www.monahrq.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/quality-resources/tools/lab-testiing/lab-testing-toolkit.pdf
    December 01, 2017 - The testing process is a system. … This guide will help you focus on your office system rather than on the performance of individual staff … Any of these steps can be a source of error if the office system allows it. … Addressing the system can reduce errors. Figure 1. … Design a change to reduce error in your office system by using a Planning for Improvements tool.
  3. www.monahrq.ahrq.gov/challenges/health-data/how-to-enter.html
    March 01, 2023 - Home Challenges Past AHRQ Challenge Competitions Integrating Healthcare System … Challenge Digital Solutions to Support Care Transitions Challenge Integrating Healthcare System … Understands that AHRQ will not select a winner that is named on the Excluded Parties List System (EPLS
  4. www.monahrq.ahrq.gov/talkingquality/resources/comparative-reports/physicians.html
    October 01, 2022 - Developer: California Office of the Patient Advocate and California Healthcare Performance Information System … the Patient Advocate (OPA) in collaboration with the California Healthcare Performance Information System … Subject: Individual physicians Developer: University of Utah Health Care Developer Type: Health system
  5. www.monahrq.ahrq.gov/sites/default/files/wysiwyg/evidencenow/cooperatives/evidencenow-executive-summary-nyc.pdf
    November 01, 2017 - 51.8% Solo 16.1% 2-5 6.7% 6-10 4.2% 11 or more 17% Unknown 66.8% Clinician owned 0% Health system-owned … 16.1% 2-5 6.7% 6-10 4.2% 11 or more 100% Urban 17% Unknown 66.8% Clinician owned 0% Health system-owned … 16.1% 2-5 6.7% 6-10 4.2% 11 or more 21.2% Unknown Ownership 66.8% Clinician owned 0% Health system-owned … The facilitation consists of: • Monthly onsite practice facilitation meetings to encourage system
  6. www.monahrq.ahrq.gov/sites/default/files/wysiwyg/evidencenow/cooperatives/evidencenow-executive-summary-northwest.pdf
    November 01, 2017 - Participating Practices: 209 45% Urban 18% Rural 36% Suburban 1% Unknown 40% Clinician owned 39% Health system-owned … more 1% Unknown 45% Urban 18% Rural 36% Suburban 1% Unknown 40% Clinician owned 39% Health system-owned … 18% Solo 53% 2-5 17% 6-10 12% 11 or more 1% Unknown Ownership 40% Clinician owned 39% Health system-owned … key areas: • Health information technology support and use of data for Physician Quality Reporting System
  7. www.monahrq.ahrq.gov/sites/default/files/wysiwyg/npsd/data/spotlights/spotlight-ptsafety-and-covid-19.pdf
    November 01, 2021 - changes in demand for services that simultaneously overwhelmed some providers and services in the system … Covid-19 – Implications for the Health Care System. … date a provider completed the Healthcare Event Reporting Form and entered the data into the provider system … The report date, or the date that the event is reported into a system by a provider, indicated that … lab on test results 4 The median number of days between a provider entering the report into their system
  8. www.monahrq.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patientsafetyculture/pharmacy/pharmwebinar/motzslides.pdf
    May 12, 2014 - Aurora Pharmacies Overview • Integrated health system • Regional pharmacy chain based in Milwaukee … to learn front-line caregivers impressions of the safety program May allow comparisons of our system
  9. www.monahrq.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/ambulatory-surgery/sections/sustainability/management/visual/visual-mgmt-facnotes.docx
    May 01, 2017 - Module 5: Visual Management SAY: As mentioned in the module on huddles, the frontline management system … SLIDE 2 Title: A Frontline Management System To Promote Safety Standard Work SAY: As the figure shows … , at the center of the frontline management system is daily work, including huddles where problems are … tracking and highlight progress in ongoing improvement work, supporting many other elements of the system … concerns list, as we’ve mentioned, can be a tool to help earn staff buy-in for the frontline management system
  10. www.monahrq.ahrq.gov/health-literacy/professional-training/lepguide/chapter2.html
    September 01, 2020 - quality and safety leaders have many opportunities to meet their obligation to build a patient safety system … Even when REL data are collected, they are rarely linked to the patient safety reporting system. … This system is just being rolled out and there is no evidence at this time on its effectiveness. … high-risk scenarios that build on a robust patient safety identification, reporting, and monitoring system … Mechanisms for Scheduling Interpreter One hospital described a system that flags previously hospitalized
  11. www.monahrq.ahrq.gov/news/blog/ahrqviews/diagnostic-safety-conversation.html
    October 01, 2021 - effectively about solutions that can help prevent errors and improve the overall performance of the system … Rather, we are examining the whole system and process of diagnosis and how to improve it. … But because of a workflow backlog, the result is not entered into the system fast enough to be interpreted … emergency department during peak hours can cause a patient who needs immediate care to be missed by the system
  12. www.monahrq.ahrq.gov/hai/pfp/2015-interim.html
    December 01, 2016 - 2015 (Preliminary) Source: AHRQ National Scorecard Estimates from Medicare Patient Safety Monitoring System … HACs, 2010 to 2015 Source: AHRQ National Scorecard Estimates from Medicare Patient Safety Monitoring System … Total = 3,097,400) Source: AHRQ National Scorecard Estimates from Medicare Patient Safety Monitoring System … progress to date in reducing HACs, much work remains to be done to ensure that the U.S. health care system … and 2014 interim reports were prepared with full-year data, the Medicare Patient Safety Monitoring System
  13. www.monahrq.ahrq.gov/sites/default/files/wysiwyg/evidencenow/heart-health/smoking-resources-help-quit.pptx
    August 27, 2018 - tools protocols/protocols.html 8 Tobacco Treatment Action Guide Actions to improve delivery system … Sample protocols Atrius Health and Harvard Vanguard Medical Associates Louisiana State University Health System
  14. www.monahrq.ahrq.gov/sites/default/files/wysiwyg/pqmp/measures/chronic/chipra-241-bmi-communication-section-1-table-1.pdf
    February 24, 2020 - V70.6, V70.8, V70.9 CPT = Current Procedural Terminology; HCPCS = Healthcare Common Procedure Coding System
  15. www.monahrq.ahrq.gov/hai/pfp/hacrate2013.html
    January 01, 2018 - since the Institute of Medicine's (IOM's) 1999 publication of To Err Is Human: Building a Safer Health System … and its subsequent 2001 publication of Crossing the Quality Chasm: A New Health System for the 21st … The medical records used for the Medicare Patient Safety Monitoring System (MPSMS) come from the CMS … 2010 to 2013* Source: AHRQ National Scorecard Estimates from Medicare Patient Safety Monitoring System … progress to date in reducing HACs, much work remains to be done to ensure that the U.S. health care system
  16. www.monahrq.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/ambulatory-surgery/sections/sustainability/management/problem-solving/problem-solving-facnotes.docx
    May 01, 2017 - Solving and Escalation SAY: In this module, we will focus on two elements in the frontline management system … SLIDE 2 Title: A Frontline Management System To Promote Safety Standard Work SAY: As the figure here … shows, the frontline management system rests on the ability of staff and supervisors to recognize problems … Remember to review the modules and component kits on the other elements of the frontline management system
  17. www.monahrq.ahrq.gov/policymakers/chipra/demoeval/what-we-learned/final-report/appc.html
    October 01, 2015 - For 2009–2013 data, Illinois sent us Medicaid Statistical Information System (MSIS) data approved by … The State is transitioning to the new data system (the Transformed Medicaid Statistical Information System
  18. www.monahrq.ahrq.gov/sites/default/files/wysiwyg/evidencenow/tools-and-materials/EvidenceNOW-Webinar-Practical-Solutions.pdf
    May 01, 2018 - HRQ recognizes that revitalizing the Nation’s primary care system is foundational to achieving high-quality … On Health IT Functionality: “It is frustrating when you purchase an EHR system and think you are … ” - Richelle Koopman, M.D., M.S., University of Missouri Health System … M.D., Chief Medical Officer, Population Health and Longitudinal Care Service Lines, Geisinger Health System … ownership, and location affect HIT use, but in unexpected ways – Urban independent practices and rural system
  19. www.monahrq.ahrq.gov/patient-safety/reports/liability/waever.html
    August 01, 2017 - Communication, Apology, and Resolution (CARe) Planning and Implementing the Patient Advocacy Reporting System … in the Sanford Health System Patient, Family Member, and Clinician Perceptions of Disclosure of Adverse … Recognizing system influences on care delivery and learning from mistakes are key elements of a culture … Why hospitals don’t learn from failures: Organizational and psychological dynamics that inhibit system … Developing a measure of system thinking: a key component in the advancement of the science of CQI.
  20. www.monahrq.ahrq.gov/sites/default/files/wysiwyg/policymakers/chipra/statesummaries/chipra-750-maryland-state-snapshot.pdf
    January 01, 2018 - Maryland also customized an electronic system that CMEs and child-serving agencies can use to report … researchers also helped child-serving agencies and CMEs establish data-sharing agreements, reduce cross-system … published an analysis of psychotropic medi- cation use and produced a report on the State’s crisis response system … • Use Substance Abuse and Mental Health Services Administration system of care grants, received in

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