Session Descriptions

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Sessions by Track

Immersion Workshops

Taking place before the general conference, these full-day workshops enable you to learn to apply new safer care methods immediately. Choose one of four workshops:

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Workshop I - Certified Professional in Patient Safety (CPPS) Review Course

Workshop I - Certified Professional in Patient Safety (CPPS) Review Course

Wednesday, May 23, 2018, 8:00AM – 3:00PM

This review course is being offered to experienced patient safety professionals who plan to take the Certified Professional in Patient Safety (CPPS) examination. This course can help participants prepare for the exam by reviewing domain content areas and test-taking strategies.

Upon completing this workshop, you will be able to:

  • Review the five patient safety domains in depth, following the exam content outline
  • Discuss patient safety scenario examples similar to actual exam questions
  • Assess your own level of preparedness for the exam and address additional areas for self-study

Taking this course counts towards 6.0 contact hours toward CPPS (Certified Professional in Patient Safety) recertification

Presenters:

  • Maureen Frye, MSN, BC, CRNP, CPPS, Director, Center for Patient Safety and Health Care Quality, Abington Memorial Hospital
  • John Hertig, PharmD, MS, CPPS, Associate Director, Purdue University College of Pharmacy Center for Medication Safety Advancement
  • Judy Milne, MSN, RN, CPHQ, CPPS, Patient Safety Officer, Duke University Medical Center
  • Dot Snow, MPH, CPPS, Director, National Risk Management & Patient Safety, Kaiser Permanente

Workshop II - Leadership Day: Leading a Culture of Safety, A Blueprint for Success

Workshop II - Leadership Day: Leading a Culture of Safety, A Blueprint for Success

Wednesday, May 23, 2018, 8:00AM – 3:00PM

The Leadership Day Immersion Workshop is designed to equip current and aspiring health care executives with tools and approaches that will enable them to create, shape, and sustain effective cultures of safety within their organization. The elimination of harm to our patients and workforce must not be just an essential priority of health care leaders, but also a moral and ethical obligation. Recognizing that navigating the complex world of health care presents daunting challenges, this interactive workshop will provide health care leaders with a framework designed to help overcome those obstacles. Through both lecture and hands-on learning, participants will be introduced to evidence-based resources and tools designed for assessing and fostering a culture of safety.

Upon completing this workshop, you will be able to:

  • Identify the six leadership domains that are essential for creating, shaping, and sustaining an effective culture of safety
  • Analyze and interpret outcomes of the Culture of Safety Organizational Self-Assessment
  • Develop actionable steps for leading organizational learning and improvement

Presenters:

  • Jeffrey Brady, MD, MPH, Director, Center for Quality Improvement and Patient Safety (CQUIPS)
  • Tim Ewing, PhD, Vice President for Talent Management and Inclusion, Baystate Health
  • Jack Lynch, FACHE, President and CEO, Main Line Health
  • Doug Salvador, MD, MPH, Chief Medical Officer, Baystate Medical Center

Workshop III - Application of Human Factors and Systems Safety Principles: Thinking Differently about Patient Safety

Workshop III - Application of Human Factors and Systems Safety Principles: Thinking Differently about Patient Safety

Wednesday, May 23, 2018, 8:00AM – 3:00PM

Upon completing this workshop, you will be able to:

  • Define the systems-based approach and apply its use to create a culture of safety
  • Describe the importance of usable technology and devices
  • Incorporate principles of device usability into safety programs to select and safely implement technology and devices in their health care environment
  • Explain concepts of human performance and cognition and make use of these in designing safer care delivery systems
  • Understand how systems can and should be designed to support the way humans work, to minimize the opportunity for error, and to mitigate the impact of error when it occurs

Presenters:

  • Natalie Benda, MS, Senior Research Fellow, National Center for Human Factors in Healthcare, MedStar Institute for Innovation, MedStar Health; PhD Candidate, Industrial Systems Engineering, University at Buffalo
  • Natalie Abts, MS, Usability Services Senior Program Manager, National Center for Human Factors in Healthcare, MedStar Institute for Innovation, MedStar Health
  • Rollin Fairbanks, MD, MS, FACEP, CPPS, Assistant Vice President, Ambulatory Quality and Safety, MedStar Health; Founding Director, National Center for Human Factors in Healthcare, MedStar Institute for Innovation, MedStar Health; Associate Professor of Emergency Medicine, Georgetown University
  • Kathryn Kellogg, MD, MPH, Associate Medical Director & Director of Human Factors Safety Integration, National Center for Human Factors in Healthcare, MedStar Health; Assistant Professor of Emergency Medicine, Georgetown University
  • Seth Krevat, MD, FACP, Assistant Vice President, Safety, MedStar Health; Assistant Professor of Clinical Medicine, Georgetown University
  • Kristen Miller, DrPH, CPPS, Senior Research Scientist, National Center for Human Factors in Healthcare, MedStar Health; Assistant Professor of Emergency Medicine, Georgetown University
  • Raj Ratwani, PhD, Acting Director, National Center for Human Factors in Healthcare, MedStar Institute for Innovation; Assistant Professor of Emergency Medicine, Georgetown University

Workshop IV - The Next Frontier to Improve Diagnosis: The New Diagnostic Team

Workshop IV - The Next Frontier to Improve Diagnosis: The New Diagnostic Team

Wednesday, May 23, 2018, 8:00AM – 4:15PM

In a major departure from the classical approach, where the physician is solely responsible for diagnosis, there is a new, patient-centric vision emerging for the diagnostic process in which improving teamwork can improve diagnosis. The core team encompasses the patient, the physician and the associated nursing staff, with each playing an active role in the process. The expanded diagnostic team includes pathologists, radiologists, allied health professionals, medical librarians, and others. In this workshop we will review some of the roles that each of these team members will need to assume, and suggest “first steps” that each team member can take to achieve this new dynamic. There will be presentations on three core areas of the team, followed by group and table discussions and communication exercises.

Upon completing this workshop, you will be able to:

  • LList the eight major recommendations to improve the quality and safety of diagnosis based on the National Academy of Medicine report on Improving diagnosis
  • Describe how the roles on the new diagnostic team can improve the diagnostic process
  • Explain how teamwork plays a critical role in improving diagnosis
  • Discuss barriers and solutions to implementing teamwork within the new diagnostic team

Presenters:

  • Kelly Gleason, RN, BSN, PhD(c), Doctoral Candidate and Co-lead of Team Core of Armstrong Institute Center for Diagnostic Excellence, Johns Hopkins University
  • Mark Graber, MD, FACP, Founder and President, Society to Improve Diagnosis in Medicine
  • Helen Haskell, President, Mothers Against Medical Error
  • Rebecca Jones, MBA, BSN, RN, CPHRM, CPPS, Director of Innovation and Strategic Partnerships, Pennsylvania Patient Safety Authority
  • Gordon Schiff, MD, Associate, Brigham and Women's Center for Patient Safety Research and Practice
  • Dana Siegal RN, CPHRM, CPPS, Director, Patient Safety Services, (interim) Assistant Vice President, CRICO Strategies


WORKSHOP A SESSIONS

Thursday, May 24, 2018, 9:45AM – 10:45AM

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A1: Our Health Care Systems Are Expanding: What Could Go Wrong?

A1: Our Health Care Systems Are Expanding: What Could Go Wrong?

Track 1: Advancing Safety Science

American health care institutions are in a period of substantial system expansion--mergers, acquisitions, and affiliations—that are often justified as improving the safety and quality of care. However, there has been little analysis of its potential risks of harm to patients. This session begins with an overview of what is known about the sources and approaches to the problem of patient safety risk from health care systems expansion. Attendees will then have an opportunity to evaluate whether and where their own health care systems carry the same (or other) risks and to share with and learn from other participants.

Upon completing this session, you will be able to:

  • Explain the mechanisms by which health system expansion can lead to patient harm
  • Evaluate attendee's own setting and identify two potential sources of risk to patients from system expansion
  • Describe two approaches to mitigating the risk of patient harm from system expansion

Presenters:

  • Susan Haas, MD, MSc, Co-Principal Investigator, Project on Patient Safety Risks of Health Systems Expansion, Ariadne Labs
  • Janaka Lagoo, MD, MPH, Surgical Safety Fellow, Project on Patient Safety Risks of Health Systems Expansion, Ariadne Labs

A2: Engaging Families to Prevent Ambulatory CLABSI

A2: Engaging Families to Prevent Ambulatory CLABSI

Track 2: Patient Safety in the Ambulatory Setting

The shift of health care delivery away from inpatient settings and into the home includes the need for home caregivers to utilize central lines, which carries significant risk of serious central line–associated blood stream infections (CLABSIs). Using improvement science methods, we developed a family-centered central-line skill development program and achieved >90% of families with documented independence in central-line care in the home, now sustained over 11 months. This session will teach families, nurses, physicians, and hospital leaders how to work together to develop and implement a learning curriculum that ensures safe central line care in the home by caregivers not medically trained and implement a program that engages families, patients, and staff to reduce associated infections.

Upon completing this session, you will be able to:

  • Define key aspects of supporting families in developing skills for safe home care
  • Develop an implementation plan using improvement science methods to adapt our central line skill development program to your own setting
  • Engage patients and families as co-producers of safe care in the home

Presenters:

  • Chris Wong, MD, MPH, CPPS, Pediatric Oncology Physician Liaison to Patient Safety and Quality, Dana-Farber/Boston Children's Cancer and Blood Disorder Center

A3: The Role of Quality and Safety Coaches in Advancing a Culture of Safety at the Bedside

A3: The Role of Quality and Safety Coaches in Advancing a Culture of Safety at the Bedside

Track 3: Culture of Safety in the Workplace

This session will provide attendees with an understanding of how an embedded safety coach can promote best practice through observation and coaching at the bedside and can drive positive culture change by serving as a role model and champion of behaviors that decrease harm, promote speaking up, and increase satisfaction for patients, families, and care teammates. Attendees will learn about: the development of the coach role from program proposal through implementation; how Quality Patient Safety (QPS) fellows promoted culture change through increasing staff comfort and acceptance with being observed providing care; and the evolution of role from QPS fellow to QPS coach.

Upon completing this session, you will be able to:

  • Define an effective model for promoting a culture of safety through real-time feedback and coaching on clinical best practices at the bedside
  • List opportunities to embed best-practice bundles, measure unit-based performance, and identify improvement opportunities at the unit level
  • Describe the elevation of Quality Patient Safety role from implementation to full assimilation into a care area

Presenters:

  • Melissa Hamlin, MSN, RN-BC, CPPS, Patient Safety and Quality Manager, Children's Hospitals and Clinics of Minnesota
  • Marcy McCracken, MBA, BSN, RN, Patient Care Manager, Children's Hospitals and Clinics of Minnesota

A4: Improving the Management of Referrals in EHRs

A4: Improving the Management of Referrals in EHRs

Track 4: Harnessing Technology to Improve Safety

When a referral is ordered in an electronic health record (EHR), providers have difficulty tracking whether the consult was completed and the patient received appropriate treatment. The referral process is complex and prone to breakdown, resulting in delayed diagnoses and other lapses in care. Using evidence and expert consensus, a group of national collaborators developed best practices for closing the loop on EHR-based referrals.

In this session, attendees will explore specific case studies from the Beth Israel Deaconess Medical Center as well as review performance dashboards and examples of how using the RCA2 approach with these harms has resulted in systemic changes.

Upon completing this session, you will be able to:

  • Identify the factors related to EHR design, implementation, and use that need to be considered and optimized to enable closed-loop referral management
  • Discuss best practices for closed-loop referral management in EHR systems using a sociotechnical approach

Presenters:

  • Hardeep Singh, MD, MPH, Chief, Health Policy, Quality and Informatics Program, Houston Veterans Affairs Health Services Research Center for Innovations
  • David Ting, MD, Chief Medical Information Officer, Massachusetts General Physicians Organization

A5: Leveraging the Entire Health System for Improved Glycemic Control

A5: Leveraging the Entire Health System for Improved Glycemic Control

Track 5: Medication Safety across the Continuum

This session will follow the journey of a health care system that identified opportunities for improvement in both the inpatient and ambulatory areas. We will discuss how we tackled variability of insulin intensification and quality of care. Several tools and strategies will be shared on how to improve adherence to best practices.

Upon completing this session, you will be able to:

  • Describe four tools to support safety in insulin intensification
  • List four approaches in implementation to the frontline teams of improvements in glycemic control

Presenters:

  • Lynn Benz, RN, MPA, Patient Education Services Director, Virginia Mason
  • Grace Lee, MD Section Head of Endocrinology, Virginia Mason Medical Center

A6: Invisible Harm: Designing Equity and Joy Initiatives to Improve Workplace Health and Safety

A6: Invisible Harm: Designing Equity and Joy Initiatives to Improve Workplace Health and Safety

Track 6: Workforce Safety: A Prerequisite for Joy in Work

Preventing patient harm starts by creating an emotionally and relationally safe, conducive, and joyful environment for the staff that work with those patients. Join this interactive breakout to learn about IHI’s frameworks for improving equity and joy in work, and how they are being applied by staff at IHI. During this session, we’ll explore how you can craft and implement similar initiatives at your organization.

Upon completing this session, you will be able to:

  • Build a shared understanding and definition of equity and joy in work and their impact on staff harm and burnout
  • Explore application of improvement science to equity and work
  • Share IHI's collective experiences of building diversity, inclusion, equity, and joy in work
  • Consider their organization's current state for equity and joy in work and opportunities for improvement

Presenters:

  • Dorian Burks, Project Manager, Institute for Healthcare Improvement
  • Jennifer Lenoci-Edwards, RN, MPH, CPPS, Executive Director Safety, Institute for Healthcare Improvement


WORKSHOP B SESSIONS

Thursday, May 24, 2018, 11:00AM – 12:00PM

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B1: Practical Applications of High-Reliability Principles in Health Care to Optimize Quality and Safety Outcomes

B1: Practical Applications of High-Reliability Principles in Health Care to Optimize Quality and Safety Outcomes

Track 1: Advancing Safety Science

Learn how application of High Reliability Organization (HRO) principles into daily healthcare work processes can successfully drive and promote improved quality clinical outcomes, safety, and culture changes. HRO principles translate to the point of care and can be utilized effectively in every patient encounter to drive practice and positive clinical quality outcomes in a culture of safety. Making an organizational cultural shift to a culture of safety is crucial to proactive adverse event management.

Upon completing this session, you will be able to:

  • Define high-reliability organization (HRO) principles
  • Describe how to apply HRO principles and human factors to daily health care work processes
  • Discuss how HRO principles drive reduction of health care–associated harm, quality outcomes, patient safety, and safety culture

Presenters:

  • Sherilyn Deakins, MS, RN, CPPS, Manager Patient Safety, Porter Adventist Hospital
  • Cynthia A. Oster, PhD, RN, APRN, MBA, ACNS-BC, ANP, FAAN, Nurse Scientist and Clinical Nurse Specialist, Critical Care and Cardiovascular Services, Porter Adventist Hospital

B2: Creating a Safety Net for Diagnostic and Medication Errors

B2: Creating a Safety Net for Diagnostic and Medication Errors

Track 2: Patient Safety in the Ambulatory Setting

Diagnostic error in the ambulatory setting is often related to challenges in follow-up to abnormal test results, leading to missed and delayed diagnoses. We describe two different programs designed to create patient safety nets, from the point of abnormal test results to ensuring appropriate follow-up with the patient. Our patient safety nets include four key components: creating electronic registries, modifying workflows to create diagnostic teams, patient outreach, and tracking follow-up. The Ambulatory SureNet Program of Kaiser Permanente Southern California focuses on the design, implementation, and ongoing management of multiple ongoing electronic surveillance programs across a wide variety of diseases and conditions. This program covers more than 4 million members and leverages an integrated delivery system and comprehensive electronic medical record, along with a small centralized team. Each case is tracked until either the proper follow-up occurs or patient refusal, noncompliance, or contraindication is documented in the electronic medical record.

Upon completing this session, you will be able to:

  • Identify high-risk conditions susceptible to diagnostic error in the ambulatory setting
  • Articulate approaches to developing ambulatory safety net programs to prevent missed and delayed diagnoses
  • Presenters:

    • Sonali Desai, MD, MPH, Medical Director, Ambulatory Patient Safety, Brigham and Women's Hospital
    • Michael Kanter, MD, Medical Director of Quality and Clinical Analysis, Kaiser Permanente

B3: Creating a Culture of Safety: An Organizational Transformation

B3: Creating a Culture of Safety: An Organizational Transformation

Track 3: Culture of Safety in the Workplace

More than 100,000 people die each year in US hospitals due to medical errors. That’s one patient death every 5 minutes and 22 seconds. Even hospitals recognized as the best are not immune to serious safety events. In 2014, Signature Healthcare decided to tackle this issue head on. Embarking on a journey to zero harm, safety became the number one priority, with a goal to reduce sentinel events by 60–80% within the first two years. Providing 2,761 employees (and counting) with training to help change personal behavior and reduce errors, a new culture was born. Attendees will learn proven and successful methods we used to affect change on our safety culture, and techniques for a launching point to create a safety bundle tailored to one’s specific organizational needs.

Upon completing this session, you will be able to:

  • Utilize knowledge of specific techniques (tools and tones) to help prevent harm to and reduce injury rate to patients and employees
  • List activities that were implemented at Signature for teaching these techniques that can be modified for their organization
  • Define methods for building and sustaining a safety culture

Presenters:

  • Kim Hollon, FACHE, President and CEO, Signature Healthcare

B4: Adherence to Recommended Electronic Health Record Safety Practices across Eight Health Care Organizations

B4: Adherence to Recommended Electronic Health Record Safety Practices across Eight Health Care Organizations

Track 4: Harnessing Technology to Improve Safety

This session is designed to educate attendees in how to organize and conduct a proactive risk assessment of the current state of their health care organization's EHR implementation and use. It will provide an understanding of the SAFER (Safety Assurance Factors for Electronic Health Record Resilience) guides along with the website on which they are stored.

Upon completing this session, you will be able to:

  • Explain how organizations can use the SAFER guides to conduct proactive risk assessments of their EHR implementation
  • Describe the variability in organizational adoption rates of SAFER recommendations
  • Know how to carry out a self-assessment of their organization
  • Be able to compare their organization's adoption state to that of other organizations around the world
  • Presenters:

    • Dean F. Sittig, PhD, Professor of Biomedical Informatics, University of Texas Health Science Center at Houston
    • Hardeep Singh, MD, MPH, Chief, Health Policy, Quality and Informatics Program, Houston Veterans Affairs Health Services Research Center for Innovations

B5: Pharmacy-Driven Admission and Discharge Medication Reconciliation

B5: Pharmacy-Driven Admission and Discharge Medication Reconciliation

Track 5: Medication Safety across the Continuum

Advocate Health Care,on its journey to eliminate serious harm resulting from medical error, identified errors related to failures in medication reconciliation as a significant opportunity for improvement. Benefits of an accurate medication reconciliation include reduced medication-related patient safety events, along with decreased morbidity and mortality, length of stay, emergency room visits and hospital readmissions. To address the issue, Advocate developed an innovative pharmacy-led program for admission and discharge reconciliation. By applying the high-reliability principle “deference to expertise,” and taking advantage of the unique skills of our pharmacists’, errors related to medication reconciliation have been reduced. This session will highlight our process for pharmacy-led medication reconciliation.

Upon completing this session, you will be able to:

  • Explain the meaning of a pharmacy driven admission and discharge medication reconciliation process.
  • Describe the relationship between medication errors and medication reconciliation on admission and discharge.
  • Describe how the absence of an accurate admission and discharge medication reconciliation can impact morbidity and mortality, length of stay, emergency room visits, and readmissions.

Presenters:

  • Monica Nornberg, MA, BSN, CPPS, Senior Nurse Patient Safety Consultant, Advocate Healthcare
  • Kersten Weber-Tatarelis, PharmD, BCPS-AQ ID, System Director of Clinical Pharmacy, Advocate Health Care

B6: A Call to Action: Exploring Moral Resilience toward a Culture of Ethical Practice

B6: A Call to Action: Exploring Moral Resilience toward a Culture of Ethical Practice

Track 6: Workforce Safety: A Prerequisite for Joy in Work

The American Nurses Association Professional Issues Panel on Moral Resilience has published a Call to Action: Exploring Moral Resilience toward a Culture of Ethical Practice. This presentation will explain the concept of moral resilience and the impact on individual nursing practice, in addition to describing the components of achieving an ethical and healthy work environment in order to ensure optimal patient outcomes. It will identify four promising areas for building individual capacities for moral resilience; provide specific recommendations for nurse leaders and organizational responsibilities toward fostering a culture of ethical practice; and highlight some of the promising solutions across the country implemented to build individual and organizational capacities for addressing the detrimental impact of moral distress and other forms of moral suffering.

Upon completing this session, you will be able to:

  • Explain the concept of moral resilience and the impact on individual nursing practice
  • Describe the components of achieving an ethical and healthy work environment in order to ensure optimal patient outcomes
  • Identify recommendations for nurses, nurse leaders, and organizations to strengthen moral resilience

Presenters:

  • Liz Stokes, JD, MA, RN, Director American Nurses Association Center for Ethics and Human Rights
  • Cynda Hylton Rushton, PhD, RN, FAAN, Anne and George L. Bunting Professor of Clinical Ethics Berman Institute of Bioethics/School of Nursing Professor of Nursing and Pediatrics Johns Hopkins University


WORKSHOP C SESSIONS

Thursday, May 24, 2018, 1:45PM – 2:45PM

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C1: Engaging Families to Improve Patient Safety

C1: Engaging Families to Improve Patient Safety

Track 1: Advancing Safety Science

Developed by the 2016 John M. Eisenberg Innovation in Patient Safety and Quality national award recipients, Patient and Family Centered I-PASS is an evidence-based, standardized, family-centered and inter-professional multimodal communication curriculum. Implementation of the program across one Canadian and six U.S. teaching hospitals was associated with a 38% reduction in preventable adverse events, as well as improvements in family and nurse engagement on rounds and various aspects of family experience with communication.

The session will be facilitated by hospitalist, parent, and nurse representatives of the Patient and Family Centered I-PASS Study Group. Participants will learn about the background, components, and implementation of the intervention through a blend of didactic and interactive sessions. This session will describe strategies for engaging families in study design, intervention development, and measurement of safety and other study outcomes. It will also detail evidence-based health literacy techniques for optimal team and family communication. Learners will identify adaptations to Patient and Family Centered I-PASS that may be required at their institution to address its culture, existing practices, and readiness for change in order to optimize effective implementation.

Upon completing this session, you will be able to:

  • Create individualized implementation plans for a structured rounding model utilizing high-reliability communication, family activation, health literacy techniques, and nurse engagement
  • List implementation barriers and solutions
  • Observe and provide structured feedback on rounds simulations

Presenters:

  • Alisa Khan, MD, MPH, Instructor of Pediactrics, Boston Children's Hospital

C2: Two-Patient Identification: It's Not Who You Know

C2: Two-Patient Identification: It's Not Who You Know

Track 2: Patient Safety in the Ambulatory Setting

This session will review a performance improvement process to increase the accuracy of patient identification leading to improved patient safety. Attendees will learn how, through application of a performance improvement methodology, they will be able to identify issues and barriers regarding accurate identification of patients and apply improvement strategies directed at behavioral versus process improvement.

Upon completing this session, you will be able to:

  • Identify barriers related to patient identification
  • Apply change management strategies through education
  • Use the D-Define, M-Measure, A-Analyze, I-Improve, and C-Control (DMAIC) tool to lead and measure process improvement efforts

Presenters:

  • Angela Stephens, MHA, MS, CPPS, Health Center Administrator, Private Diagnostic Clinic, Duke University
  • Dariele Cooper, CPPS, Health Center Administrator, Private Diagnostic Clinic, Duke University

C3: Creating and Sustaining a Culture of Safety

C3: Creating and Sustaining a Culture of Safety

Track 3: Culture of Safety in the Workplace

The IHI/NPSF Lucian Leape Institute and the American College of Healthcare Executives have developed Leading a Culture of Safety: A Blueprint for Success, which provides health care leaders methods and tools to build and sustain a culture of safety. In this session, leaders will learn practical strategies and tactics required by each level of the organization to drive change and embed a culture of safety throughout their organizations.

Presenters:

  • Doug Salvador, MD, MPH, Chief Medical Officer, Baystate Medical Center

C4: Saving Septic Patient Lives by Utilizing Clinical Decision Support

C4: Saving Septic Patient Lives by Utilizing Clinical Decision Support

Track 4: Harnessing Technology to Improve Safety

Middlesex Hospital, a 275-bed community hospital in Connecticut, was able to reduce sepsis mortality by 31% from their baseline. This presentation will share strategies used to reduce and sustain a reduction in sepsis mortality. We will discuss how clinical decision support was utilized by creating alerts to the right person, at the right time, in the right context, which helped eliminate serious safety events related to a delay in identification and treatment of sepsis. Presenters will share how ongoing monthly review of missed opportunities for the SEP-1 Core Measure helped the team identify potential gaps to improve the sepsis care provided and pinpoint enhancements needed to optimize clinical decision support. Participants will take away an understanding of how leveraging technology can be used to improve patient care and outcomes.

Upon completing this session, you will be able to:

  • Learn strategies in using decision support to aid in the early identification and treatment of sepsis
  • Understand the technological strategies utilized to improve compliance with CMS sepsis core measures
  • Recognize the value of positive reinforcement to Staff for excellent care of sepsis patient

Presenters:

  • Terri Savino, MSN, RN, CPHQ, Manager, Patient Satisfaction and Service Excellence, Middlesex Hospital
  • Veronica Szkop, MBA, CPHQ, Quality Improvement Coordinator, Middlesex Hospital

C5: Opioids: The Little Pill That Causes So Much Pain

C5: Opioids: The Little Pill That Causes So Much Pain

Track 5: Medication Safety across the Continuum

Patients continue to suffer harm from the opioid medications we prescribe. While we strive to improve safety, the opioid epidemic is complex and requires a multifaceted, long-term strategy. Where to begin? And how to journey down the path of improving opioid safety? We will describe the Everett Clinic’s experience with improving the safety of opioid prescribing. Our approach recognizes the importance of both culture and system improvements. This program has three components: appropriate pain control (opioids only when necessary); safe opioid prescribing (compliance with best practice); high-risk chronic opioid therapy (COT) patients (identify and manage patients at high risk of overdose and death). We aim to have an interactive presentation, where attendees can brainstorm and identify a few concrete, next-step action items. What will you do differently on Monday to improve opioid safety?

Upon completing this session, you will be able to:

  • Describe the role of culture and systems in solving the opioid epidemic
  • Define a strategy to improve opioid safety

Presenters:

  • Kent Hu, MD, MPH, Associate Medical Director of Quality and Patient Safety, The Everett Clinic, A DaVita Medical Group
  • Dianna Chamblin, MD, Facility Medical Director Comprehensive Pain Center, The Everett Clinic, A DaVita Medical Group

C6: Promoting Advanced Practice Professionals' Accountability for Safe, Kind, Reliable Care

C6: Promoting Advanced Practice Professionals' Accountability for Safe, Kind, Reliable Care

Track 6: Workforce Safety: A Prerequisite for Joy in Work

Increasing recognition of the impact unprofessional behavior has on patient safety, clinical outcomes, and teamwork means health care leaders need tools and reliable processes for identifying and addressing providers who undermine a safety culture. Using case-based, interactive teaching methods, group discussion, and practice exercises, participants will learn proven tools and techniques for having "awareness" conversations to help advanced practice nurses and physician assistants (and other professionals) recognize an actionable pattern of slips and lapses in professional behavior. Discussion will include a process of graduated interventions as illustrated by a “professional accountability pyramid”; essential elements organizations need for an reliably addressing behaviors that undermine a culture of safety; and the range of measured intervention outcomes when applied to advanced practice professionals at a large academic medical center.

Upon completing this session, you will be able to:

  • Describe relationships between clinician behaviors that undermine a safety culture and optimal outcomes
  • Identify a method for identifying and addressing advanced practice professionals with a pattern of unprofessional behaviors
  • Define essential program supports

Presenters:

  • April Kapu, DNP, APRN, ACNP-BC, Associate Nursing Officer, Advanced Practice; Director, Office of Advanced Practice
  • Tom Catron, Associate Professor of Medical Education and Pediatrics, Vanderbilt University Medical Center


WORKSHOP D SESSIONS

Friday, May 25, 2018, 8:45AM – 9:45AM

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D1: Patient and Family Harm from Disrespect: Applying an RCA2 Approach to Patient Experience

D1: Patient and Family Harm from Disrespect: Applying an RCA2 Approach to Patient Experience

Track 1: Advancing Safety Science

In 2015 we began to extend the processes that have been used to prevent physical harms to the important, but traditionally neglected, emotional harms that our patients and their families experience within the health care system. We are using the RCA2 approach to understand and mitigate future risk for events that result in these preventable harms. Our Patient and Family Advisory members have been involved in this work from inception and are advising on all its aspects, from the identification of events, to the categorization of events, to the resultant performance improvements actions following our analyses. We will use several specific case studies in this session and will share examples of how using the RCA2 approach with these harms has resulted in systemic changes.

Upon completing this session, you will be able to:

  • Describe a novel framework for detecting, analyzing, categorizing, and learning from emotional harms from disrespect
  • Apply the RCA2 framework methodology to several case examples
  • Review how findings can be shared to drive improvements in your institution

Presenters:

  • Patricia H. Folcarelli, RN, MA, PhD, Vice President, Health Care Quality, Beth Israel Deaconess Medical Center
  • Lauge Sokol Hessner, MD, Associate Director of Inpatient Quality, Beth Israel Deaconess Medical Center

D2: Advancing the Safety of Care in the Home Setting: Findings from an Expert Panel

D2: Advancing the Safety of Care in the Home Setting: Findings from an Expert Panel

Track 2: Patient Safety in the Ambulatory Setting

Care in the home setting is expanding as a result of rising health care costs, a rapidly growing older adult population, patient preference, and technological innovations. However, clinical safety in this setting is less well understood than in other settings. This session will present findings from a recent expert panel discussion on the issues, challenges and opportunities related to the safety of care in the home setting. Expert panel co-chairs, Drs. Bonner and Muething, will also discuss the panel’s recommendations for advancing patient safety in this setting.

Upon completing this session, you will be able to:

  • Describe patient safety issues associated with care in the home setting
  • Identify strategies for advancing the safety of care in the home setting

Presenters:

  • Alice Bonner, PhD, RN, Secretary, Massachusetts Executive Office of Elder Affairs
  • Stephen E. Muething, MD, Co-Director, James M. Anderson Center, Professor of Pediatrics, Michael and Suzette Fisher Family Chair for Safety, Cincinnati Children’s Hospital Medical Center

D3: Never Event Action Teams: An Innovative Approach to Improving Patient Safety

D3: Never Event Action Teams: An Innovative Approach to Improving Patient Safety

Track 3: Culture of Safety in the Workplace

In September 2015, the Canadian Patient Safety Institute (CPSI) delineated 15 "never events" for hospital care in Canada, focusing on adverse events that have been demonstrated to be reliably preventable. This session will describe the 15 never events and review North York General Hospital's creation and implementation of 15 Never Event Action Teams (NEATs) to lead the identification, development, and implementation of strategies to mitigate and decrease the likelihood and/or severity of all 15 CPSI never events. Focusing on the challenges of pursuing complex, wide-ranging projects within resource-constrained settings, the session will adopt an interactive format, guiding participants through the process of considering the feasibility of adopting the NEATs model within their unique organizational settings.

Upon completing this session, you will be able to:

  • Describe the Never Event Action Teams model
  • Elucidate strategies for the successful implementation of patient safety initiatives in resource-constrained settings
  • Demonstrate that significant patient safety outcomes can be achieved when organizations collaborate with patients and families

Presenters:

  • Katie Anawati, BSc, BScN, RN, Patient Safety & Risk Specialist, North York General Hospital

D4: Cyber Security

D4: Cyber Security

Track 4: Harnessing Technology to Improve Safety

Details for this session will be available shortly.

D5: Improving Medication Safety for Seniors at Home

D5: Improving Medication Safety for Seniors at Home

Track 5: Medication Safety across the Continuum

Medications play an expanding role in health care as we age, and seniors face many risk factors and safety concerns related to medication mismanagement. The Community Medication Education, Data and Safety (C-MEDS) program offers clinical, educational, safety and support services at no charge to seniors and caregivers at home. This session presents the pilot program, evaluation findings, and outcomes. Outcomes focus on the ability of the program to reduce safety issues among community-dwelling seniors identified as being at risk for medication mismanagement. Participants will increase their knowledge of risk factors associated with poor medication adherence and medical mismanagement among seniors, approaches to improving communication and coordination of care between prescribers, pharmacists, patients, and caregivers, and interventions found successful in promoting safe medication management practices in the home.

Upon completing this session, you will be able to:

  • Describe three risk factors often associated with safety, poor medication adherence and medication mismanagement in older adults
  • Identify three barriers older adults and family caregivers experience in managing (or assisting an older adult to manage) medications at home
  • Identify three best practices for reducing poor medication adherence and medication mismanagement

Presenters:

  • Marsha J. Meyer, PharmD, BCGP, CGCM, Director, Health and Wellness Services, Independence at Home: A Community Service of SCAN Health Plan

D6: Impact of Harm: Promoting Emotional Well-Being among Clinicians after Adverse Events

D6: Impact of Harm: Promoting Emotional Well-Being among Clinicians after Adverse Events

Track 6: Workforce Safety: A Prerequisite for Joy in Work

This presentation describes the impact of an unexpected clinical event on employee psychological safety, professional quality of life, and emotional adjustment. Participants will gain insights into the lived experience of clinicians suffering as “second victims,” understand evidence-based interventional strategies, and comprehend specific strategies for personal as well as institutional support. The discussion will also provide participant awareness on key institutional interventional strategies to aid in mitigating clinician distress in order to promote individual clinician and team resilience. An introduction of various tools to measure the use and success of a second victim program will be reviewed.For those participants with existing supportive interventions, they will be provided with tips and insights into evolving programs to optimize emotional well-being of their workforce.

Upon completing this session, you will be able to:

  • Describe an overview of the lived experience of clinicians in the aftermath of an unanticipated clinical event
  • Identify and describe supportive interventional strategies to help support the suffering clinician
  • Identify tools that can be used to assess supportive strategies

Presenters:

  • Jenna Merandi, PharmD, MS, CPPS, Medication Safety Manager, Nationwide Children's
  • Susan D. Scott, PhD, RN, CPPS, FAAN, Manager, Patient Safety and Risk Management, University of Missouri Health Care


WORKSHOP E SESSIONS

Friday, May 25, 2018, 10:00AM – 11:00AM

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E1: The Business Case for an Innovative Systems Approach to Safety and Risk: Doing the Right Thing for Our Patients

E1: The Business Case for an Innovative Systems Approach to Safety and Risk: Doing the Right Thing for Our Patients

Track 1: Advancing Safety Science

The purpose of this panel will be to share the methods and structure that a large health system has used to demonstrate a dramatic improvement of quality, safety, and risk management (QSRM) outcomes. Their seven-year transformation focused on a quality and safety program leveraging human factors engineering principles and married to an existing innovative risk management program. The health care organization has now experienced 4 consecutive years of progressively increasing significant savings on QSRM costs, demonstrating a clear return on investment and a business case for this innovative integrated QSRM approach. The approach, methods, and outcomes will be described in a lightning round–type panel discussion presented by the experts who designed and currently lead each component of the system. This will be followed by discussion and audience participation.

Upon completing this session, you will be able to:

  • Describe MedStar Health’s primary, secondary, and tertiary prevention model for analyzing, identifying, and mitigating quality, safety, and risk management vulnerabilities
  • Describe the measurable outcomes of an integrated quality, safety, and risk management program

Presenters:

  • Rollin (Terry) Fairbanks, MD, MS, FACEP, CPPS, Assistant Vice President, Ambulatory Quality and Safety, MedStar Health; Founding Director, National Center for Human Factors in Healthcare, MedStar Institute for Innovation, MedStar Health; Associate Professor of Emergency Medicine, Georgetown University

E2: Reaping Rewards, Overcoming Barriers: Partnering with Patients in Care Redesign

E2: Reaping Rewards, Overcoming Barriers: Partnering with Patients in Care Redesign

Track 2: Patient Safety in the Ambulatory Setting

The value of patient and family engagement in quality improvement is becoming increasingly recognized. While literature is still emerging, evidence finds patient engagement takes many forms, is feasible, and can be both satisfying and frustrating. This session draws on experience of four project teams testing strategies for engaging patients in quality improvement projects as part of an AHRQ patient safety learning lab. Learning about how to better engage patients has been an important objective of the lab. This session highlights the value of partnering with patients on quality improvement teams, roles patients can play, lessons learned about effective partnerships, and strategies for overcoming resistance and challenges to patient engagement.

Upon completing this session, you will be able to:

  • Recognize 3 to 5 important roles that patients can play on improvement teams and select at least one new opportunity for engaging patients in ongoing improvement work that can be initiated starting with your next team meeting
  • Develop problem solving strategies for overcoming clinician team members’ potential resistance or concerns to involving patients in improvement work.
  • Cultivate processes for identifying, engaging, sustaining, and measuring patient partner participation in improvement projects.

Presenters:

  • Sara Singer, MBA, PhD, Professor, Stanford University
  • Erin Ward, MSEd, Parent; Patient Partner; Redesign Team Member, Boston Children’s Hospital

E3: Clinician-Directed Performance Improvement

E3: Clinician-Directed Performance Improvement

rack 3: Culture of Safety in the Workplace

Christus St. Vincent Regional Medical Center (CSVRMC), a 200-bed community hospital in Santa Fe, New Mexico, developed a quality program designed to give practicing clinicians protected time, support, and training to conduct performance improvement projects of their choosing. The program has generated 33 projects with a 92% success rate (defined as demonstrating statistically significant improvement), and has been associated with large improvements in physician engagement, culture of safety, and patient experience. In this session, attendees will learn how to empower frontline clinicians to direct quality improvement based on their expertise and insight.

Upon completing this session, you will be able to:

  • Describe key aspects of a program to engage frontline clinicians in quality improvement
  • Describe key contributions of frontline clinicians to hospital quality programs
  • Describe advantages to moving beyond a narrow institutional focus on externally reported quality metrics
  • Describe the connection between quality improvement and hospital culture

Presenters:

  • Lara Goitein, MD, Medical Director, Clinician-Directed Performance Improvement, Christus St. Vincent Regional Medical Center

E4: Harnessing the Electronic Health Record to Optimize Monitoring and Follow-Up of Oral Anti-Cancer Therapies

E4: Harnessing the Electronic Health Record to Optimize Monitoring and Follow-Up of Oral Anti-Cancer Therapies

Track 4: Harnessing Technology to Improve Safety

UCHealth is a 9-hospital health system located on the Front Range of the Rocky Mountains. In 2016, UCHealth Cancer Care diagnosed or treated more than 6,400 analytic cases. In this presentation, we will discuss how we formulated a response to our organizational need for improved monitoring of adherence and toxicity of patients taking oral cancer therapy medications. Our response plan included creation of consents, policies, educational plans for staff, creation of treatment plans, alerts to signal follow-up phone calls when a patient starts a medication, alerts to signal during the patient visit that the patient is on a medication, and follow-up reporting of staff compliance with completing the required monitoring. Examples of the treatment plans, alerts including clinical decision support mapping, and reporting metrics will be provided.

Upon completing this session, you will be able to:

  • Review challenges of monitoring and follow-up relating to oral anti-cancer therapies (ACT)
  • Suggest strategies surrounding clinical decision support to alert staff of patients receiving oral ACT
  • Examine reporting mechanisms to increase staff compliance with best practices relating to oral ACT

Presenters:

  • Kate Jeffers, PharmD, MHA, BCOP, Ambulatory Oncology Clinical Specialist, UCHealth
  • Amy Walde, Quality Assurance Manager, UCHealth

E5: Improving Medication Safety by Incorporating Indications into Prescribing, Communicating, and Educating about Drugs

E5: Improving Medication Safety by Incorporating Indications into Prescribing, Communicating, and Educating about Drugs

Track 5: Medication Safety across the Continuum

Currently, medication orders omit a critical piece of information: the drug indication, i.e., the reason for taking the drug. Integrating indications could pave the way for a safer, more complete continuum of care and save time during prescribing and related tasks (e.g., medication reconciliation). Indications-based prescribing has the potential to revolutionize prescribing by reengineering the prescriber workflow to incorporate indications. In addition, it has the potential to increase patient medication safety, adherence, and knowledge. We used a user-centered design process to develop an innovative indications-driven CPOE prototype and conducted head-to-head testing against two leading EMR commercial vendors (Epic, Cerner) to compare efficiency, satisfaction and error rates. We will discuss our findings from this trial, and what they mean for the future of indications-based prescribing.

Upon completing this session, you will be able to:

  • Demonstrate the importance of incorporating indications into medication orders
  • Evaluate the design of an indications-based prescribing prototype
  • Compare the results with two different approaches taken to prescribing workflow

Presenters:

  • Gordon Schiff, MD, Associate, Brigham and Women's Center for Patient Safety Research and Practice
  • Pamela Neri Garabedian, Project Specialist, Partners HealthCare Systems

E6: Promoting an Injury-Free Workplace: Our Health System's Journey

E6: Promoting an Injury-Free Workplace: Our Health System's Journey

Track 6: Workforce Safety: A Prerequisite for Joy in Work

With increases in patient volumes, acuity levels, and workplace demands, is it really possible for health care organizations to increase reporting while reducing injuries? By implementing a solid accident and incident investigation process as an essential component of your safety program—it is. Participants in this session will learn why taking a proactive vs. reactive approach to safety will help identify the conditions that cause incidents before they happen. They will also learn how conducting a thorough root-cause analysis will help to identify the what, how and why an incident happened, so that steps can be taken to prevent a reoccurrence. Additionally, session attendees will learn to understand how soliciting coworker feedback, bringing injury awareness to all levels within the organization and employing a multi-disciplinary, non-punitive injury review process can assist with the reduction of recordable injuries, non-recordable injuries and near misses.

Upon completing this session, you will be able to:

  • Build leader engagement for injury prevention
  • Apply analysis principles to worker injury data to develop benchmarks and goals
  • Implement a program for worker injury reporting, investigation, hazard identification, and risk reduction
  • Achieve effective accountability for worker safety

Presenters:

  • Jeffrey Boord, MD, MPH, Chief Quality Officer, Parkview Health
  • Anna Belote, Director of Safety and Emergency Preparedness, Parkview Health
  • Diane Casey, Director of Occupational and Employee Health, Parkview Health


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