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1. Module 3: Problem Solving and Escalation | 1
AHRQ Safety Program for Ambulatory Surgery
Management Practices for Sustainability
Management Practices for Sustainability
Module 3: Problem Solving
and Escalation
AHRQ Safety Program for Ambulatory Surgery
AHRQ Pub. No. 16(17)-0019-4-EF
May 2017

2. Module 3: Problem Solving and Escalation | 2
AHRQ Safety Program for Ambulatory Surgery
Management Practices for Sustainability
A Frontline Management System To Promote
Safety Standard Work
Daily Safety Huddle
• Standard agenda
• Data review
• Problem tracking
Visual Management
• Outcomes over time
• Checklist compliance
• Problem log
Escalation
• Sentinel events
• Problems raised in
huddle
Safety Work by Staff
• Using surgical checklist
• Infection control
procedures
Observation of
Safety Work: unit
lead & senior leader
Problem Solving
• Compliance
• “Just Fix It”
• Investigate causes
• QI* project
Integration With Leaders
• Senior leader unit review
• Escalation from procedure
• Escalation from daily
huddle
* Quality improvement

3. Module 3: Problem Solving and Escalation | 3
AHRQ Safety Program for Ambulatory Surgery
Management Practices for Sustainability
What Is a Problem? What Is a Solution?
Concept Example
Problem: An undesirable gap between an
expected state and the actual state of a system.
(1) Expected: Each operating room team will use
an agreed-to script during procedure timeouts.
(2) Actual: On May 23 at 10:30 a.m., two team
members did not audibly speak at the timeout.
(3) Problem: Less than 100 percent of team gave
an audible check.
Solution: Closes the undesirable gap between
the expected state and the actual state.
• A type 1 solution closes the immediate gap.
• A type 2 solution prevents recurrence of the
gap in the future.
(1) Type 1: Supervisor observing the surgical
team on May 23 at 10:30 a.m. intervenes to ask
team members to audibly confirm "ready."
(2) Type 2: Supervisor works with staff to
understand the cause of the problem and acts to
prevent recurrence.

4. Module 3: Problem Solving and Escalation | 4
AHRQ Safety Program for Ambulatory Surgery
Management Practices for Sustainability
How Do Problems Get Flagged?
• Most problems are identified by staff or are observed by
supervisors.
• The daily huddle gives you a place and time every day to
speak up about problems observed by team members.
• Weekly observation of procedures and work methods by the
supervisor, as actually performed, is another primary source.
The supervisor can also bring observations to the daily
huddle.

5. Module 3: Problem Solving and Escalation | 5
AHRQ Safety Program for Ambulatory Surgery
Management Practices for Sustainability
Four Problem Boxes

6. Module 3: Problem Solving and Escalation | 6
AHRQ Safety Program for Ambulatory Surgery
Management Practices for Sustainability
Apply the Model for Improvement To Improve
Your Problem Solving
• What are you trying to accomplish? Reduce the number of
recurring problems
• How will you know that a change is an improvement? Fewer
problems of the same kind flagged in huddle and observed at
work
• What can you change to make an improvement?
Try the Problem Triage flowchart as your initial guide

7. Module 3: Problem Solving and Escalation | 7
AHRQ Safety Program for Ambulatory Surgery
Management Practices for Sustainability
Apply the Model for Improvement To Improve
Your Problem Solving–2
• Plan: Lay out the specifications of your test
• Do: Conduct the test
• Study: Review how the test went and lessons learned
• Act: Integrate your learning into your next test or into daily
practice
7

8. Module 3: Problem Solving and Escalation | 8
AHRQ Safety Program for Ambulatory Surgery
Management Practices for Sustainability
Escalation for Frontline Clinical Issues
• Safety issues arise at the front line that require immediate
action by staff
• Facilitate escalation by using CUS
– I am Concerned
– I am Uncomfortable
– This is a Safety issue
• Example of the CUS-style escalation process is in the
component kit for this module

9. Module 3: Problem Solving and Escalation | 9
AHRQ Safety Program for Ambulatory Surgery
Management Practices for Sustainability
Tips
• Problem solving as we've described aims to achieve
and maintain reliable performance
• If your organization has a standard problem-solving
method, learn to use it
• Understand the tools for root cause analysis that
your center applies to investigate and document
harm events
• Incorporate routine use of CUS into frontline work;
ensure broad staff understanding and comfort with
use