Slide Presentation of the 2007 Annual Meeting of AHRQ

"Culture eats Strategy for Breakfast" -Glyn Elwyn

Notes:

Culture of changes in workflow...

Hundreds of hours invested in preparing, reviewing, education and practicing workflows.

Necessity or personal decision drove a need to "regress" or "ignore" these workflows...

Impact was errors in pharmacy charging—through charge on dispense and charge on admin.

Lost appreciation for change in scope of action of data...