www.ahrq.gov/sites/default/files/wysiwyg/hai/tools/mrsa/167-hospital-level-gap-analysis.pdf
April 02, 2025 - Is an infection preventionist assigned to each intensive care unit (ICU) in the hospital? … Is an infection preventionist assigned to each non-intensive care unit (non-ICU) in the hospital? … How often does the infection preventionist visit their unit(s) routinely? … Secret observations by unit staff
Secret observations by individual(s) not from the unit
… Ongoing observations on the units
Unit self-assessments
Periodic observation assessments
www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/mvp/modules/cusp/forming-cuspteam-facguide.docx
January 01, 2017 - Bundle
Slide Title and Commentary
Slide Number and Slide
Title Slide
Forming a Comprehensive Unit-based … Safety Program Team
SAY:
Today, we will briefly revisit the key concepts of the Comprehensive Unit-based … Slide 10
Team Roles—Unit Manager
SAY:
The unit manager is often either a nurse manager or unit manager … The unit manager mentors the team to speak up and identify defects. … Third, use unit-level data and staff inputs to drive improvement efforts.
www.ahrq.gov/sites/default/files/wysiwyg/action-alliance/teamwork-ptsafety-norms-slides.pdf
March 18, 2025 - the understanding that all culture is local
and that work to improve culture must be owned at
the unit … Implementation
• Developed multidisciplinary team
► Included all 3 ICUs, medical directors of each unit … response to “how will the next patient
be harmed”
► Rolled out house-wide with expectation
that each unit … Improving teamwork: Impact of structured interdisciplinary rounds on a medical teaching unit. … done in ICUs and all units in hospital
• Hard initiative to implement, especially if you have an open unit
www.ahrq.gov/news/newsroom/case-studies/ktcquips50.html
October 01, 2014 - Hubbell and her colleagues made presentations to each unit or department that participated in the AHRQ … Hubbell and her colleagues then led discussions with each unit about ways to improve performance. … These discussions served as the basis for developing action plans for each unit, which were finalized … According to Hubbell, the telemetry unit was one of the units that did not have high scores on the survey … improve performance, the organizational development department was tasked with assisting the telemetry unit
www.ahrq.gov/sites/default/files/wysiwyg/sops/events/webinar/05-sops-teamstepps-webcast-mazur.pdf
April 30, 2022 - reality training)
26
Agenda
Longitudinal analysis of SOPS scores
Cross-sectional analysis of unit-based … data only)
Communication about error 82 +15
We are informed about errors that happen in this unit. … 80 +15
When errors happen in this unit, we discuss ways to
prevent them from happening again. 84 + … 14
In this unit, we are informed about changes that are
made based on event reports. 82 +16
TENTS … At the unit level: Identify positive and negative aspects of culture
of patient safety and relate them
www.ahrq.gov/sites/default/files/wysiwyg/hai/tools/mrsa/024-assessing-evc-webinar-slides.pptx
October 01, 2024 - for FG Monitoring5
Study results: Three randomly selected HTSs from two randomly selected rooms per unit … every 2 weeks is the optimal strategy
Optimal strategy to predict FG removal on a unit
For five units … Evaluate two rooms of a unit and three HTSs within those rooms.
Set up random and blinded monitoring … Nurse
Role
Unit Nurse
Advantages
Strengthens collaboration and facilitates discussion between EVC and … Level Feedback
Disseminate data at unit CUSP and quality improvement meetings.
www.ahrq.gov/hai/cusp/clabsi-neonatal/nclabsi4.html
January 01, 2013 - States and number of units participating in initiative *
* One unit is located in Georgia, a State … 6,783 (39.4)
Approximately 90 percent of central lines were new (8 percent placed outside the unit … new lines placed
Procedures Followed
Without
Prompt
With
Prompt
Not Done
Unit … Team Check-Up Tool
The number of unit teams submitting Team Check-Up Tool data per month has varied … burden") and one question showing a drop below baseline levels in the last data collection period ("Unit
www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/cauti-tools/impl-guide/implementation-guide.pdf
September 01, 2015 - Intensive Care Unit Infographic Poster
Appendix M. … When used with the Comprehensive Unit-based Safety Program (CUSP) Toolkit, the
practices outlined in … Culture consists of the unit team’s values, attitudes, and
beliefs, which will all have an impact on … Catheters
placed for surgery duration should be removed in the post-anesthesia care unit. … Post this
metric in the nursing station of your unit or on a hallway bulletin board.
www.ahrq.gov/patient-safety/settings/labor-delivery/perinatal-care/modules/teamwork/board-checklist.html
July 01, 2023 - Set expectation for unit-level culture assessment.
4. … Set the expectation that a senior leader is an active member of each Comprehensive Unit-based Safety … (*"How is the next patient likely to be harmed on my unit? What might we do to prevent that harm?")
www.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/long-term-care/resources/ontime/fallsprev/fallpxreports.pptx
October 01, 2017 - Prevention
Electronic Reports
Electronic Reports
Falls High-Risk Report
Summary of Fall Risk Factors (by Unit … or Facility)
Contextual Factors Report (by Unit or Facility)
Postfall Assessment Report (by Resident … Falls Prevention
24
Summary of Falls Risk Factors Report
Report displays falls information at the unit … Nursing Unit:
Date: ___/___/___
October 2017
On-Time Falls Prevention
27
Check Your Understanding … A Unit B Unit C
Monday 0 1 0
Tuesday 0 2 0
Wednesday 2 1 1
Thursday 0 1 1
Friday 0 2 1
Saturday
www.ahrq.gov/sites/default/files/wysiwyg/sops/surveys/hospital/hospital-ve-supp-item-set-08-2022.pdf
January 01, 2022 - To Improve Efficiency
How much do you agree or disagree with the following statements about your unit … In our unit, we are working to improve patient
flow. .............................................. … In our unit, we take steps to reduce patient
wait time. ........................................... … Provides us with reports on our unit
performance .................................................. … I looked at visual displays or graphs to see how well my unit was performing. ...........
www.ahrq.gov/hai/tools/mrsa-prevention/toolkit/program-implementation.html
December 01, 2024 - Stewardship
Blood Culture Practices and Stewardship
Index of Clinical Topics
The Comprehensive Unit-based … Toolkit Implementation Guide for MRSA Prevention in the ICU and Non-ICU (DOCX, 887 KB) Tool: Unit-Level … MRSA Prevention (PDF, 905 KB) An assessment of current practices relevant to MRSA Prevention in your unit