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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/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/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/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/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/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/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/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
-
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
-
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.
-
www.ahrq.gov/news/events/nac/2019-07-nac/nacmtg0719-minutes.html
November 01, 2019 - learning systems into processes such as decision support. … What is the role of AHRQ in artificial intelligence systems? … How might we design systems more attuned to individuals? … What data systems will be most helpful? Electronic health records have potential. … (The data were from for-profit health systems.)
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www.ahrq.gov/sites/default/files/wysiwyg/research/findings/nhqrdr/chartbooks/carecoordination/qdr2015-chartbook-carecoordination.pdf
June 16, 2016 - Data Support Contractors: Booz Allen Hamilton (BAH), Fu Associates, Social & Scientific Systems (SSS) … Hospitals with computerized systems that allow electronic clinical documentation. … Hospitals with computerized systems that allow results viewing. … Hospitals with computerized systems that allow decision support. … Systems That Allow Computerized Physician Order Entry With a Medication Component
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www.ahrq.gov/practiceimprovement/delivery-initiative/ihs/chap5tab13.html
December 01, 2017 - Fiscal year 2010
ARRA Grants Initiative
Findings from a set of 16 grants on improving delivery systems … and on spreading evidence-based practices through delivery systems; recommendations and methods for
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www.ahrq.gov/research/findings/final-reports/crcscreeningrpt/crcscreentab3-6.html
April 01, 2018 - Health Care Systems for Tracking Colorectal Cancer Screening Tests
Table 3.6. … Response Rates, by Practice
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Health Care Systems
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www.ahrq.gov/research/findings/final-reports/crcscreeningrpt/crcscreentab4-7.html
April 01, 2018 - Health Care Systems for Tracking Colorectal Cancer Screening Tests
Table 4.7. … Patients, by Practice Affiliation
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www.ahrq.gov/research/findings/final-reports/crcscreeningrpt/crcscreentab4-1.html
April 01, 2018 - Health Care Systems for Tracking Colorectal Cancer Screening Tests
Table 4.1. … by County and Sex, 2002-2006
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www.ahrq.gov/diagnostic-safety/resources/issue-briefs/dxsafety-psychological-safety-4.html
September 01, 2023 - Within healthcare systems, efforts to help team members and consultants become familiar with each other … leadership can support and incentivize event reports with well-designed and user-friendly reporting systems … Optimal systems will build capacity for measuring and monitoring diagnostic quality in support of quality … framework can guide such assessments and includes technological factors and external forces such as payment systems … may involve analysis of events, engage team members, and support a comprehensive assessment from a systems
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www.ahrq.gov/research/findings/final-reports/crcscreeningrpt/crcscreentab4-18.html
April 01, 2018 - Health Care Systems for Tracking Colorectal Cancer Screening Tests
Table 4.18. … Recommended or Not Recommended Action
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Health Care Systems