AHRQ's Quality & Patient Safety Programs by Setting: Hospital

Communication and Optimal Resolution (CANDOR) Toolkit enables health care organizations to implement an AHRQ-developed process. Like similar programs in place in other organizations, CANDOR gives hospitals and health systems the tools to respond immediately when a patient is harmed and to promote candid, empathetic communication and timely resolution for patients and caregivers. Based on expert input and lessons learned from the Agency's $23 million Patient Safety and Medical Liability grant initiative launched in 2009, the CANDOR toolkit was tested and applied in 14 hospitals across three U.S. health systems.

Each of the toolkit's eight modules contains PowerPoint slides with facilitator notes. Some modules also contain tools, resources, or videos.

Fall TIPS: A Patient-Centered Fall Prevention Toolkit consists of a formal risk assessment and tailored plan of care for each patient. The toolkit has reduced falls by 25 percent in acute care hospitals and is used in more than 100 hospitals in the U.S. and internationally.

Family-Centered Rounds (FCR) Toolkit was designed to increase family engagement in rounds for hospitalized children. It is intended for use by health care providers initiating FCR and/or operationalizing optimal practices in the setting of existing FCR, including: physicians, nurses, hospital administrators, and quality improvement personnel.

Guide for Developing a Community-Based Patient Safety Advisory Council provides approaches for hospitals and other health care organizations to use to develop a community-based advisory council that can drive change for patient safety through education, collaboration, and consumer engagement.

Guide to Patient and Family Engagement in Hospital Quality and Safety helps hospitals work as partners with patients and families to improve quality and safety. Includes an implementation handbook and tools for patients, families, and clinicians.

Hospital Guide to Reducing Medicaid Readmissions provides evidence-based strategies to reduce readmissions among the adult Medicaid population.

Hospital SOPS is a staff-administered survey that helps hospitals assess how their staff perceive various aspects of safety culture.

I-PASS Mentored Implementation Handoff Curriculum is a comprehensive handoff curriculum that has been proven to improve the safety, efficiency, and efficacy of shift-to-shift handoffs during patient handoffs.

Making Informed Consent an Informed Choice: Training Modules for Health Care Leaders and Professionals provides tools to hospital leaders and health professionals to improve informed consent policy and practice.

Medical Alarm Audibility System Checker (MAASC) is a Java-based software tool for checking whether medical alarms within a modeled configuration can ever be rendered inaudible due to simultaneous masking between concurrently sounding medical alarms. MAASC will also allow analysts to check whether a given alarm configuration is consistent with the IEC 60601-1-8 international medical alarm standard. Instruction for installing and running tool can be found at MAASC website.

Medications at Transitions and Clinical Handoffs (MATCH) Toolkit features strategies from the field that can help hospitals improve medication reconciliation processes for patients as they move through the healthcare system.

Multi-Center Medication Reconciliation Quality Improvement Study (MARQUIS) Toolkit includes a set of medication reconciliation tools to reduce medication errors that frequently occur during care transitions when patients enter and leave the hospital.

Network of Patient Safety Databases Chartbook provides an overview of data captured by Patient Safety Organizations on the nature of patient safety events in hospital settings.

Preventing Falls in Hospitals: A Toolkit for Improving Quality of Care focuses on overcoming the challenges associated with developing, implementing, and sustaining a fall prevention program. Includes an implementation guide to help put prevention strategies into practice.

• Fall Prevention in Hospitals Training Program supports the training of hospital staff on how to implement AHRQ's Preventing Falls in Hospitals Toolkit. It consists of a five-module, in-person training curriculum and a series of companion Webinars on specific topics related to fall prevention. An Implementation Guide provides additional suggestions for how to use the training program and the toolkit.

Preventing Hospital-Associated Venous Thromboembolism: A Guide for Effective Quality Improvement outlines the latest evidence on how to lead a quality improvement effort to prevent hospital-acquired venous thromboembolism.

Preventing Pressure Ulcers in Hospitals is a toolkit that assists hospital staff in implementing effective pressure ulcer prevention practices through an interdisciplinary approach to care.

• Pressure Injury Prevention in Hospitals Training Program supports the training of hospital staff on how to implement AHRQ's Preventing Pressure Ulcers in Hospitals Toolkit. It consists of a five-module, in-person training curriculum and a series of companion webinars on specific topics related to pressure injury prevention. An Implementation Guide provides additional suggestions for how to use the training program and the toolkit.

Project BOOST (Better Outcomes by Optimizing Safe Transitions provides hospitals a comprehensive set of interventions to improve the care transition process after discharge in order to reduce readmissions.

REDUCE MRSA (Methicillin-Resistant Staphylococcus aureus) Enhanced Protocol explains that universal decolonization is the most effective intervention to reduce MRSA infections. This tool provides instructions for implementing decolonization in adult intensive care units.

Re-Engineered Discharge (RED) Toolkit is a research-based tool to assist hospitals, including those that serve diverse populations, in improving their hospital discharge process and reducing avoidable readmissions. An English/Spanish guide to help staff ensure that patients understand their discharge instructions is also available.

Safe OR Design Tool is an interactive web-based tool that uses a 3D model to support clinicians, designers, and researchers in better understanding how to design a safer, more ergonomic operating room (OR). The tool engages multidisciplinary team members in a more collaborative design process when designing OR environments and provides a comprehensive understanding of how different design elements and strategies affect safety in the OR, using a systems approach. 

Toolkit for Decolonization of Non-ICU Patients With Devices
This toolkit can help hospital infection prevention programs implement a decolonization protocol that was found to reduce bloodstream infections by roughly 30 percent in adult inpatients who were not in intensive care units and who had specific medical devices. It includes implementation instructions, demonstration videos, and customizable tools.

Toolkit for Improving Surgical Care and Recovery
This toolkit helps hospitals implement evidence-based practices to improve outcomes and prevent complications among patients who undergo surgery.

Toolkit to Improve Antibiotic Use in Acute Care Hospitals provides presentations and tools for clinicians to use to improve antibiotic prescribing in the hospital setting. The toolkit explains how you can apply the Four Moments of Antibiotic Decision Making, an innovative approach to antibiotic stewardship that empowers clinicians to be stewards of their own antibiotic prescribing. The toolkit also provides guidance on developing and improving your antibiotic stewardship program, creating a culture of safety around antibiotic prescribing in your hospital, and learning and disseminating best practices for the diagnosis and treatment of common infectious disease syndromes.

Toolkit for Preventing CLABSI and CAUTI in ICUs
This customizable, educational toolkit aims to help hospital intensive care units (ICUs) reduce rates of central line-associated bloodstream infection (CLABSI) and catheter-associated urinary tract infection (CAUTI). Using the Comprehensive Unit-based Safety Program (CUSP) and other evidence-based practices, the toolkit helps ICUs assess their current CLABSI and CAUTI prevention efforts, has resources to help ICUs overcome common challenges in infection-reduction efforts, and provides the clinical and cultural guidance to make changes needed to decrease CLABSI and CAUTI rates.

Toolkit for Using the AHRQ Quality Indicators: How To Improve Hospital Quality and Safety helps hospitals understand AHRQ's Quality Indicators and how to use them to identify areas of concern in need of further investigation, and monitor progress over time. 

Transitioning Newborns from NICU to Home: A Resource Toolkit provides customizable resources to help hospitals and families safely transition newborns out of the neonatal intensive care unit to home using a Health Coach Program.