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521. Using Root Cause Analysis to Help Practices Understand and Improve Their Performance and Outcomes (pdf file)
     ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/ncepcr/tools/PCMH/pcpf-module-11-root-cause-analysis.pdf
     December 27, 2021 - As a practice facilitator (PF), you will want to help your practices take a step back from their data … Organizational causes include processes, procedures, and policies that are contributing to the problem … Organizational causes: The empanelment procedures do not include training and monitoring the appointment … You should be able to teach the process to practice members so they can use it on their own, and also … Have the categories of causes already pre-filled with people, environment, materials, methods, equipment

522. Designing and Delivering Whole-Person Transitional Care: The Hospital Guide to Reducing Medicaid Readmissions - Toolbox (pdf file)
     ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/medicaidreadmitguide/medread-tools.pdf
     July 28, 2016 - identified opportunities that your hospital team can address (e.g., bedside delivery of medication, teach-back … planning  Use clinical pharmacists to enhance medication optimization, education, reconciliation  Use “teach-back … care] • [peer support programs] • [customized patient information] • [social support services] • [teach‐back … Provide customized education to patients and their caregivers;  Provide oral instructions using the teach-back … This can also be a useful supplemental method of research for resources you may not have thought of.

523. Module 2: How To Manage Change—Training Guide | Agency for Healthcare Research and Quality
     ce.effectivehealthcare.ahrq.gov/patient-safety/settings/hospital/fall-prevention/workshop/module-2/guide.html
     September 01, 2017 - Links to quality improvement expertise—someone with expertise in systematic process improvement methods … Instructor’s Note: The specific type of quality improvement method/framework/tool used is not important … You can use colored sticky notes, as in this example, or some other method, and work with the unit staff … problems are specific to each unit, because of differences in patient population, medications, and methods … patient-safety/settings/hospital/fall-prevention/workshop/module-2/guide.html   Back

524. The National Action Alliance to Advance Patient Safety Summer Webinar Series - PowerPoint Presentation (pdf file)
     ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/action-alliance/public-action-alliance-slides-040323_LOCKED.pdf
     May 25, 2023 - hospitalized improved for: ► acute myocardial infarction, ► heart failure ► pneumonia ► major surgical procedures … Safety current state 2) Establish Group Rules - Check your Ego at the Door 3) Establish Purpose - All Teach … at te m pt s Fa lls C LA BS I M R SA B ac te re m ia Leadership Safety culture All teach … Description Recommended Actions 7–11 Just Beginning • Create an action plan for and use improvement science methods … highly encouraged • Provided 2.5hour workshops for all managers, expert facilitator • What we heard back

525. Diagnostic Failure: A Cognitive and Affective Approach (pdf file)
     ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol2/Croskerry.pdf
     January 01, 2004 - This involves being able to step back from the immediate pull of the situation to momentarily reflect … Heighten metacognition Train for a reflective approach to problem-solving: stepping back from the immediate … Cognitive aids and debiasing methods: can cognitive pills cure cognitive ills?

526. Department of Veterans Affairs Emergency Airway Management Initiative (pdf file)
     ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety-2/vol1/Advances-Stalhandske_71.pdf
     February 23, 2008 - Methods The VA confirmed the need for this effort by reviewing the available literature and by capturing … conditions that often are quite trying.2 One respiratory care department published their experience as back-up … • Use of alternative methods of intubation that are in practice at each hospital with an actual patient … Learning manual skills in anesthesiology: Is there a recommended number of cases for anesthetic procedures … pub_ID=1292 Abstract Introduction Methods Results Survey of Facilities Discussion Personnel

527. TeamSTEPPS® Teamwork Perceptions Questionnaire (T-TPQ) Manual | Agency for Healthcare Research and Quality
     ce.effectivehealthcare.ahrq.gov/teamstepps/instructor/reference/teamperceptionsmanual.html
     April 01, 2017 - Return to Contents Cognitive Interviews Method . … Return to Contents Small Group Trial Method . … Return to Contents Field Test Method. … This is the preferred method for performing data analyses. … www.ahrq.gov/teamstepps/instructor/reference/teamperceptionsmanual.html   Back

528. Barriers Associated with Medication Information Handoffs (pdf file)
     ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol3/Bayley.pdf
     January 01, 2004 - charts because of technical constraints, equipment maldistribution, and multiple clinician access procedures … detailed care process maps that documented the flow of information from ambulatory to acute care and back … Our method for rating failure-effect combinations therefore results in somewhat lower frequency scores … Efforts are underway to teach patients how to keep themselves safe and to be reliable conduits for medication … Probabilistic risk analysis, foundations and methods.

529. Monitoring for Perinatal Safety: Electronic Fetal Monitoring: Facilitator Guide | Agency for Healthcare Research and Quality
     ce.effectivehealthcare.ahrq.gov/patient-safety/settings/labor-delivery/perinatal-care/modules/strategies/safe-electronic-fac-guide.html
     July 01, 2023 - Identify ways to apply key safety elements to your unit policies, procedures, and practices related to … that uses formal tools or analysis for learning from defects and sensemaking, including some of the methods … Support implementation of Key Safety Elements through— Unit policies and procedures. … Test any new procedures on a limited scale to work out any bugs or problems. … /perinatal-care/modules/strategies/safe-electronic-fac-guide.html   Back

530. References | Agency for Healthcare Research and Quality
     ce.effectivehealthcare.ahrq.gov/patient-safety/settings/hospital/vtguide/guideref.html
     July 01, 2018 - Venous thromboembolism prevention: a systematic review of methods to improve prophylaxis and decrease … Challenges in implementing government-directed VTE guidance for medical patients: a mixed methods study … A validation study of a retrospective venous thromboembolism risk scoring method based on the Caprini … Venous thromboembolism prevention: A systematic review of methods to improve prophylaxis and decrease … www.ahrq.gov/patient-safety/settings/hospital/vtguide/guideref.html   Back

531. Using Six Sigma® Methodology to Improve Handoff Communication in High-Risk Patients (pdf file)
     ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety-2/vol3/Advances-Mistry_114.pdf
     May 05, 2008 - Methods: The existing handoff process was evaluated and improved using Six Sigma® methodology and medical … Often compared to the scientific method, this approach consists of the following five steps that are … In health care, for example, this may involve new methods to detect medication errors. … involved in a patient’s recent care did not consistently participate; (2) the handoff content and method … high-reliability organizations to utilize structured communication techniques, such as checklists and “read-back

532. Preventing CAUTI in Specialized Patient Populations: The ICU | Agency for Healthcare Research and Quality
     ce.effectivehealthcare.ahrq.gov/hai/cauti-tools/archived-webinars/preventing-cauti-specialized-populations-icu.html
     December 01, 2017 - Healthcare-Associated Infections Program Combating Antibiotic-Resistant Bacteria About the CUSP Method … At that time, instructions will be given as to the procedure to follow if you would like to ask a question … gave us a baseline data of where we stood on our unit, and just kind of looked at our policies and procedures … 49:22 indiscernible) staff on female urinal use and we also started revising our Foley policies and procedures … I do think that that's definitely a culture change that goes back to what Dr.

533. Appendix A: Tools and Resources | Agency for Healthcare Research and Quality
     ce.effectivehealthcare.ahrq.gov/patient-safety/settings/hospital/vtguide/appa.html
     July 01, 2018 - a much higher risk. 6,7 The high incidence of postoperative VTE and the availability of effective methods … FREE Registry study, half the inpatients who suffered from VTE were nonsurgical and had no surgical procedures … A Validation of a Retrospective Venous Thromboembolism Risk Scoring Method. … We meet the criteria for Description No. 4 and we also have other methods to reinforce protocol guidance … //www.ahrq.gov/patient-safety/settings/hospital/vtguide/appa.html   Back

534. TeamSTEPPS® Diagnosis Improvement: Module 1 Introduction
     ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/teamstepps/diagnosis-improvement/module1-introduction.pptx
     January 12, 2022 - Research has shown that teams that communicate effectively and back each other up reduce the potential … The ultimate diagnosis may not be effectively communicated back to the patient, with clear communication … Teach-Back. Briefs. Huddles.   … He did mention that some tests were done in pulmonary clinic that he never heard back about, which I … Putting Socrates back in Socratic method: theory-based debriefing in the nursing classroom.

535. Strategy 3: Nurse Bedside Shift Report Implementation Handbook (doc file)
     ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/engagingfamilies/strategy3/Strat3_Implement_Hndbook_508.docx
     August 01, 2010 - tri-fold checklist provides information about how to fold the brochure by indicating the front and back … As needed, identify alternative methods or outlets for nurses to talk with one another. … To help clarify these situations for staff nurses, your hospital may want to establish procedures for … Often, if bedside shift report is not consistently monitored, nurses may revert back to familiar habits … In March 2009, the three nurse champions attended a course focusing on quality improvement methods and

536. Module 15: Preparing and Presenting Performance Data (pdf file)
     ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/ncepcr/tools/PCMH/pcpf-module-15-presenting-data.pdf
     September 01, 2015 - ............................................................................... 3 Describing Your Methods … available at: http://www.lanetpbrn.net/wp-content/uploads/Performance-Report-Generator_1.xlsb) or another method … Another method is to run frequencies using a statistical program. … A number of good online training programs teach basic skills for working with data using statistical … For each performance metric, you should clearly describe the methods you used to obtain the data, the

537. Presentation: Program Overview
     ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/surgery/modules/onboarding/onboarding_overview_impmodel.pptx
     December 01, 2017 - National improvement effort for hospitals of all sizes and any surgical procedure type Designed to reduce … SSIs and other surgical complications for any procedure type Overview ‹#› AHRQ Safety Program … Program will teach you to embed adaptive work (CUSP) in your technical work (surgical care) Unlike other … If, so what data collection method was used? Survey? Interviews? Focus groups? Alternative method? … Take these steps back to your team and complete the premortem exercise during your first surgical safety

538. TeamSTEPPS® Diagnosis Improvement: Module 1 Introduction (pdf file)
     ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/teamstepps/diagnosis-improvement/module1-presenters-notes.pdf
     January 12, 2022 - Research has shown that teams that communicate effectively and back each other up reduce the potential … • The ultimate diagnosis may not be effectively communicated back to the patient, with clear communication … • Teach‐Back. • Briefs. • Huddles. … He did mention that some tests were done in pulmonary clinic that he never heard back about, which … Putting Socrates back in Socratic method: theory-based debriefing in the nursing classroom.

539. TeamSTEPPS: Rapid Response Systems (pdf file)
     ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/professionals/education/curriculum-tools/teamstepps/rrs/instructor_slides/rrsinstructmod.pdf
     January 01, 2008 - The organization selects a suitable method that enables health care staff members to directly request … Think back to our example in the first video we watched. … •A handoff back to the primary nurse or primary physician. … Let’s think back to the RRS we saw in action earlier. … • What procedures could be put into place to avoid the confusion of what room the response team

540. SITUATION MONITORING (ppt file)
     ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/professionals/education/curriculum-tools/teamstepps/rrs/rrsinstructmod.ppt
     January 01, 2008 - The organization selects a suitable method that enables health care staff members to directly request … Think back to our example in the first video we watched. … A handoff back to the primary nurse or primary physician. … Let’s think back to the RRS we saw in action earlier. … What procedures could be put into place to avoid the confusion of what room the response team should