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www.ahrq.gov/research/findings/final-reports/crcscreeningrpt/crcscreenfig3-2.html
April 01, 2018 - Health Care Systems for Tracking Colorectal Cancer Screening Tests
Figure 3.2. … SATIS-PHI/CRC Intervention Study
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Table of Contents
Health Care Systems
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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-Neuspiel_43.pdf
March 05, 2008 - Harewood, MPA
Abstract
Objective: We aimed to determine the effectiveness of team-based reporting, systems … A systems approach—as advocated by the IOM—is a shift from a traditional blaming culture,
which seeks … Health care personnel have limited experience in identifying faulty systems, which are
responsible for … The new competency
requirements in systems-based care from the Accreditation Council of Graduate Medical … Interventions have included staff education, changes in
systems, and equipment modifications.
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www.ahrq.gov/prevention/guidelines/tobacco/clinicians/presentations/2008update-full/slide79.html
October 01, 2014 - Evidence has shown that clinic screening systems such as expanding the vital signs to include tobacco-use … status, or the use of other reminder systems such as chart stickers or computer prompts significantly
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www.ahrq.gov/patient-safety/patients-families/consumer-exp/reporting/appb.html
August 01, 2022 - Designing Consumer Reporting Systems for Patient Safety Events
Appendix B. … Reviewers
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Table of Contents
Designing Consumer Reporting Systems
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www.ahrq.gov/sites/default/files/wysiwyg/news/events/nac/2022-05-nac/nacmtg051222-minutes.pdf
January 01, 2022 - AHRQ has been working with healthcare systems throughout the nation, where
consolidation has occurred … Melinda Buntin, Ph.D., complimented AHRQ on taking a systems-view through the years. … She stated that
bias and disparities, as well as physician burnout, persist in systems. … Examples of good- shared
governance in healthcare systems exists. Dr. … AHRQ can pursue follow through, determining how to
improve systems.
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www.ahrq.gov/research/findings/final-reports/crcscreeningrpt/crcscreensum.html
April 01, 2018 - Health Care Systems for Tracking Colorectal Cancer Screening Tests
Executive Summary
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Table of Contents
Health Care Systems for Tracking Colorectal Cancer Screening … the screening and followup process through improved eligibility identification and screening tracking systems … primary care practices in the Lehigh Valley that affected both their electronic medical record (EMR) systems … closely affiliated with the central entity and those that have and do not have fully functional EMR systems
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol1/Duthie.pdf
January 01, 2004 - Root cause analyses (RCA) that examine systems issues and identify mechanisms
for future prevention … Tightly coupled systems are those in which an action is taken that directly
affects the outcome. … and reactively analyze systems
to achieve better outcomes. … American Society of Health Systems Pharmacists. … Leape LL, Bates DW, Cullen DJ, et al., Systems
analysis of adverse drug events.
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www.ahrq.gov/sites/default/files/wysiwyg/hai/tools/clabsi-cauti-icu/tiered-approach-notes.docx
April 01, 2022 - Team and ICU Staff module, defects that result in error leading to harm are most often a result of systems … To achieve optimal outcomes, organizations must design strong systems that minimize the risks of us making … When creating these systems, you will want to design it to support desired human behaviors. … Organizations can manage both system and human behavior through development of learning systems, which … Slide 8
With the key concepts of “Just Culture” and systems theory being the backbone, CUSP can be
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www.ahrq.gov/patient-safety/settings/hospital/candor/modules/notes8.html
August 01, 2022 - step involves using the knowledge and the momentum from short-term wins to align an organization’s systems … Robust, transparent feedback systems —The CANDOR process components that correspond with transparent … feedback systems are Response and Disclosure and Event Analysis. … Shared sense of the systems to be improved —The entire CANDOR process fosters a culture of improvement … CANDOR team leaders can continue to build systems for collecting process, outcome, and QI activity data
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www.ahrq.gov/prevention/guidelines/tobacco/clinicians/presentations/2008update-overview/slide10.html
October 01, 2014 - Systems interventions, including provider training and the combination of training and systems interventions
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www.ahrq.gov/ncepcr/tools/confid-report/app2.html
March 01, 2016 - Part One: Physician Feedback Report Fundamentals
Part Two: Design of Physician Feedback Reporting Systems … Part Three: Three Strategies for Continuous Improvement of Physician Feedback Reporting Systems … Part Four: A Research Agenda To Advance the Science of Physician Feedback Reporting Systems
Concluding
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www.ahrq.gov/patient-safety/reports/hotline/preface.html
May 01, 2016 - Recommendations for Ideal Consumer Reporting Systems
Appendix B. … The report should be of interest to policymakers, leaders of health care systems and their related organizations … researchers, and others who are interested in the development and deployment of patient safety reporting systems
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www.ahrq.gov/ncepcr/research-transform-primary-care/transform/synthesis-report/execsumm.html
October 01, 2015 - Primary care transformation is a process that practices or health systems choose to engage in, rather … However, the capabilities of the existing EHR systems varied widely across practices studied by the TPC … Traditional payment systems that reward quantity rather than quality of health services may compromise … three studies suggest that patients welcomed and valued the enhanced access offered through online systems … The findings and lessons learned from the TPC grants may be useful for practices and health care systems
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/primary-care/tpc/tpc-profile-gabbay.pdf
April 01, 2015 - including
private practices, Federally
Qualified Health Centers, and
practices belonging to health
systems … Providers also reported feeling more confident in their skills and
in the support systems established … needed resources such as additional staff (e.g., medical assistants and nurse care
managers), EHR systems … most-improved
clinical outcomes had greater structural
capabilities (e.g., EHRs and stable financial
systems … For additional information about this grant, please visit:
http://www.ahrq.gov/professionals/systems
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/mvp/modules/cusp/science-of-safety-slides.pptx
January 01, 2017 - Because…
People are fallible
We expect providers to be perfect
We focus on individuals as opposed to systems … Most errors do not belong to individual doctors and nurses
Health care systems are rarely designed to … Factors
Patient Characteristics
Apply System Lenses
Engage staff by asking them to apply systems … What systems may have led to these events? … Safety Program for Mechanically Ventilated Patients
15
Where To Find Defects
Adverse event reporting systems
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www.ahrq.gov/ncepcr/reports/grants-transform/executive-summary.html
March 01, 2017 - Primary care transformation is a process that practices or health systems choose to engage in, rather … However, the capabilities of the existing EHR systems varied widely across practices studied by the TPC … Traditional payment systems that reward quantity rather than quality of health services may compromise … three studies suggest that patients welcomed and valued the enhanced access offered through online systems … The findings and lessons learned from the TPC grants may be useful for practices and health care systems
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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-Clarke_8.pdf
January 25, 2008 - already in use, but that existing systems should be mapped to the standards in
an evolutionary way. … systems. … Other patient safety
reporting systems capturing large volumes of near-miss reports, such as the UHC … PSET may be most appropriate for new patient
safety reporting systems or small systems for which changes … Patient safety as an
organizational systems issue: Lessons from a variety
of industries.
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www.ahrq.gov/prevention/guidelines/tobacco/clinicians/presentations/2008update-full/slide22.html
October 01, 2014 - Systems features
No intervention.
Clinical training. … Clinical training and reminder systems.
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www.ahrq.gov/sites/default/files/publications/files/confidreportguide_1.pdf
March 01, 2016 - Part Two: Design of Physician Feedback Reporting Systems
2-1. … Systems that enable physicians to correct patient-level data
3-2. … Part Two: Design of Physician Feedback Reporting Systems
2-1. … Systems that enable physicians to correct patient-level data
3-2. … Part Two: Design of Physician Feedback Reporting Systems
2-1.
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www.ahrq.gov/research/findings/final-reports/crcscreeningrpt/crcscreen5.html
April 01, 2018 - Health Care Systems for Tracking Colorectal Cancer Screening Tests
5. … , insurers owned or operated by delivery systems, insurers not owned or operated by delivery systems, … Delivery systems, insurers, and public health agencies throughout Pennsylvania. … Delivery systems in the current CNA Health ACTION Team network. … Delivery systems in other ACTION partnerships.