Day One - November 19, 2008
Pre-conference Workshops (8:30-11:45 am)
Option #1
Meta-Leadership for Patient Safety: Building System Connectivity - An Interactive Workshop
Meta-Leaders leverage and expand health care capacity by strategically linking people, information, expertise, and knowledge. The session presents the concepts and practice of meta-leadership, and illustrates how to build system connectivity for patient safety. Participants will be engaged in an interactive workshop to problem solve meta-leadership solutions and become proactive within their own organizations.
Leonard J. Marcus, PhD
Founding Co-Director, National Preparedness Leadership Initiative, A Joint Program of the Harvard School of Public Health and Kennedy School of Government
Option #2
The 2009 National Patient Safety Goals
This session will provide an overview of the Joint Commission's National Patient Safety Goals (NPSGs) and related requirements. The focus of this session will be on current expectations in meeting these Requirements and the major challenges that health care organizations and the Joint Commission are facing in seeking to overcome identified barriers to success. Strategies for implementing both the current and the new 2009 Goals and Requirements will be presented.
Louise Kuhny, RN, MPH, MBA, CIC
Senior Associate Director, Standards Interpretation
The Joint Commission
1:00-1:15 pm
Opening/Welcome
Conference Moderator
Peter B. Angood MD, FRCS(C), FACS, FCCM
Vice-President & Chief Patient Safety Officer
The Joint Commission
1:15-2:30 pm
Presidential Overview - The Joint Commission's Role in Quality and Safety
Mark R. Chassin, MD, MPP, MPH
President, The Joint Commission
2:30-2:45 pm
Break
2:45-4:15 pm
Opening Plenary - Leadership for Quality and Patient Safety
On January 7, 2002, Paul Levy became CEO of the Beth Israel Deaconess Medical Center. He took over a troubled organization, in serious financial difficulty. This presentation describes how a talented CEO took charge of a troubled organization and began the turnaround process focusing on quality, safety and sustained improvements. Mr. Levy will showcase leadership styles, management philosophies, the change process dilemma, and the importance of communication strategies in decision making.
Paul Levy
President and Chief Executive Officer
Beth Israel Deaconess Medical Center
Author, Running a Hospital
4:15-4:30 pm
Closing Comments
Peter B. Angood MD, FRCS(C), FACS, FCCM
Vice-President & Chief Patient Safety Officer
The Joint Commission
Day Two - November 20, 2008
7:15-8:00 am
Optional Breakfast Briefing: The Standards. Your Access. Your way.
Today it's all about access. That's why Joint Commission Resources is giving your more access soltuions than ever. That includes the new Edition online database and the powerful new Accreditation Manager Plus (AMP) electronic toolkit. Come find out more about the options for electronic access to the Joint Commission standards.
Sara L. Randall
Software Product Manager
Joint Commission Resources
8:15 - 8:30 am
Update/Announcements
Peter B. Angood MD, FRCS(C), FACS, FCCM
8:30 - 10:00 am
The State and Direction of Patient Safety and Culture ... or If-Then
Work with Stephen Harden to see what would happen!
IF you created a better environment for your physicians to practice medicine THEN you would gain improved physician satisfaction.
IF you created a better work environment for your nurses and staff, THEN you would gain improved employee satisfaction, less nurse turnover, lower replacement and "agency" costs IF you created fewer undetected and uncorrected errors by your care givers THEN you would gain improved patient satisfaction leading to improved market share.
Stephen Harden
President, Lifewings Partners, LLC
10:00 - 10:15 am
Break
10:15 - 11:30 am
Plenary
Leading Health Care to a Safer Place (for Patients)
Keeping patients safe requires competent, vigilant frontline staff; involved, supportive managers; and visible, compassionate, effective leaders. In fact, much emphasis has been placed on the leadership attention that is necessary to establish a culture of safety within a health care organization. This briefing will highlight leadership concepts including structure, relationships, organization culture, system performance expectations and operations. Best practices for implementing these goals, along with focusing on patient safety and quality of care will be presented by a CEO who has identified innovated practices for implementation.
Deborah M. Nadzam, PhD, FAAN
Practice Leader, Patient Safety Services
Joint Commission Resources
Christopher J. Durovich
President and Chief Executive Officer
Children’s Medical Center Dallas
11:30 - 12:45 pm
Lunch
Afternoon - Tracks
Track - Patient Care
Moderator:
Deborah M. Nadzam, Ph.D., F.A.A.N.
Practice Leader, Patient Safety Services
Track - Patient Safety
Moderator:
Peter B. Angood MD, FRCS(C), FACS, FCCM
Vice-President & Chief Patient Safety Officer
The Joint Commission
Track - Operational Assessments
Moderator:
Charles J. Macfarlane, FACHE
Vice President, Learning
Joint Commission Resources
12:45 - 2:00 pm
Track - Patient Care
Condition H: - Partnering with Patients and Families, Response to (Encouraging Patient's Active Involvement in Care)
Without effective communication families and patients may feel their questions or concerns are being over looked or not addressed. Believing that patients and families should have a way to tell us when they feel something is not right with their medical care, UPMC Presbyterian began the patient safety initiative of
Condition "Help." Learn how this effective communication plan could be applicable to your organization.
Amanda Fritz, BA
Process Improvement Specialist
University of Pittsburgh Medical Center - Presbyterian Campus
Laurie Rack, RN, BSN, MSN
Clinical Director, Patient Support Services
University of Pittsburgh Medical Center - Presbyterian Campus
Track - Patient Safety
Medication Reconciliation Across an Integrated Health System
Fairview Health Services is a fully integrated system of seven hospitals, 30 primary care clinics, home care, hospice, home infusion agencies and other programs. In 2006, Fairview counted more than 81,000 discharges. Electronic health records, medication processes and medical staff structures differ across Fairview. Such diversity renders a single approach to reconciliation unachievable. In 2005 Fairview leaders set an objective to achieve full medication reconciliation system-wide, reducing reconciliation-related errors and potential adverse drug events.
Steven Meisel, Pharm.D.
Director of Medication Safety, Fairview Health Services
Nancy Dimunation, RN
Chief Nursing Officer
Fairview Red Wing Medical Center
Track -Operational Assessments
Fire Risk Assessment - A Score for Patient Safety
Approximately 100 fires in operating rooms are reported annually. In 2004, Christiana Care Health System (CCHS) sought to improve their approach to fire safety during surgical procedures. After examining existing protocols, a comprehensive and reliable approach to surgical fire prevention was implemented. Learn how a fire risk assessment tool was developed that could be integrated into standard operations.
Kenneth Silverstein, MD
Chair, Dept. of Anesthesiology
Christiana Care Health System
Judy Townsley, RN, MSN, CPAN
Director of Clinical Operations, Perioperative Serivces
Christiana Care Health System
Denise Dennison, RN, BSN
Staff Development Specialist, Christiana Care Health System
2:00-2:15 pm
Break
2:15-3:30 pm
Track - Patient Care
Mayo Emergency Department Leans on Allergy Bands for Improved Patient Safety
The Emergency Department at St. Mary's Hospital (Mayo Clinic, Rochester MN) is an academic ED with 78,000 visits per year. In 2007, this ED began a process improvement project to improve the efficiency, effectiveness, and safety of patient care through lean improvement methodology. Hear how staff based teams met to create current state process maps. The improvement team identified key improvement action plans within their goal of allergy bands. 1) Define the appropriate place in the care process for applying allergy bands and set accountability standards. 2) Eliminate the manual and non-value added steps of the process. 3) Create a way to print bands so they are legible and consistent with electronic allergy module
Vernon Smith, MD
Consultant, Department of Emergency Medicine
Mayo Clinic
Lori Scanlan-Hanson, BSN, MS
Continuous Improvement Specialist
Department of Emergency Medicine
Mayo Clinic, Rochester
Track - Patient Safety
Screening and Implementation of a DVT Prophylaxis Program for Medical/Surgical Population in an Acute Care Setting
This presentation is focused on assisting acute care hospitals in implementing a screening/prophylaxis program for VTE. The focus is on the facts, individual risk and patient population risk. The goal is to screen 100 percent of your inpatient population, assist hospitals in developing standardized forms in which to deliver appropriate care and reduce errors.
The presentation will review the methods of educating staff (pharmacy, nursing, and physician) on risk factors and appropriate prophylaxis. Learn the methods and tips for educating staff when you return to your organization.
Mary Foscue, MD
Assistant Vice President of Medical Affairs
Sacred Heart Hospital
Hella Ewing, RN, BSN, MSM
Administrative Director Women Services/NICU
Sacred Heart Hospital
Track -Operational Assessments
Patients at Risk of Suicide: Documenting the Suicide Risk Assessment and Treatment Plan
Suicide is a tragic and preventable public health problem, which claims at least 30,000, lives annually in the United States. Suicide is a relatively rare occurrence and there are no reliable quantitative tools for assessing risk. What's more, there is no universally accepted definition of an adequate suicide risk assessment. Guidelines are available however, to assist clinicians in identifying patients at risk of suicide. This presentation will review the efforts of a large metropolitan Behavioral Health program to develop a consistent approach for documenting both the risk assessment and the treatment plan.
Jeffery Young, MD
Medical Director of Regional Adult Behavioral Health Services
Providence Health
Brenda Anderson, RN
Providence Health
3:30-4:45 pm
Track - Patient Care
Public Disclosure of Healthcare Assoc. Infections and Reporting: Succeeding at the National Consensus Standards, Infection Control
During this presentation, Dr. Fishman will bring a body of medical knowledge in developing guidance in the workplace setting and health procedures and practices to succeed at the National Consensus Standards on Infection Control. Patterns and trends will be discussed as well as tips for ongoing improvements.
Neil Fishman, MD, Associate Professor of Medicine
Division of Infectious Diseases
University of Pennsylvania
Track - Patient Safety
Policies to Ensure Communication and Patient Safety - A Standardized Approach
Learn how BWH has been working to implement a standardized approach to hand off communication among care providers when a patient is transferred from one setting to another. Hear about how this organization ultimately created a policy through phasing to address OR-to-PACU hand offs; nurse-to-nurse hand offs; and resident and physician assistant hand offs. Challenges, obstacles, and lessons learned will be reviewed in-depth.
Kristin Styer, MSN,RN
Quality Program Manager
Perioperative Nursing
Brigham and Womens Hospital
Track -Operational Assessments
Tracing for Excellence: Safer Patients and Larger Savings for Healthcare
Immanuel St. Joseph's - Mayo Health System embarked on a journey in the fall of 2005 to improve compliance with National Patient Safety Goals (NPSGs) and other Joint Commission standards. The value of performing internal mock tracers has helped them to identify safety concerns before these reach the patient. In addition, internal tracers have shown an improved level of preparedness in meeting NPSG's and Joint Commission standards.
Learn how this organization found a way to emulate the tracer experience that The Joint Commission uses to ensure that staff always had safety at the top of their priorities. Discuss will provide an in-depth review of the way that would discover the successes and opportunities for improvement in a manner similar to that used by Joint Commission Surveyors.
Judy Webber, RN, BN, CIC
Manager, Quality Resources
Immanuel St. Joseph's - Mayo Health System
Tamara Merchlewitz, RN, MA
Director, Organizational Learning
Immanuel St. Joseph's - Mayo Health System
4:45 pm
Adjourn
Day Three - November 21, 2008
7:30-8:15 am
Optional Breakfast Briefing
Pediatric Patient Safety
Medical errors, including pediatric medical errors continue to be at the forefront of the news and in the minds of patients. Keeping pediatric patients safe at all times is part of the National Patient Safety Goals. This discussion will share JCR's passion in providing the best in patient care, best practices, expert advice, and strategies to build and sustain a culture of safety in your organization.
Francine Westergaard, MSN, RN
Consultant
Joint Commission International
Joint Commission Resources
8:30 - 8:45 am
Update/Announcements
8:45 - 10:00 am
Plenary
When An Error Happens You Can Do Three Things
Ms. Conrad's interest in patient safety began as a result of the death of her late husband, astronaut Charles "Pete" Conrad. Pete Conrad was privileged to participate in the Gemini, Apollo, and Skylab programs. He commanded the second lunar landing and received the Congressional Space Medal of Honor for his rescue of Skylab. Although his life was spent in programs based on systems excellence, he died the preventable death of a systems failure. An international speaker at industry and academic forums in the field of quality care, Ms Conrad's compelling story serves to personalize the need for patients and their families to take responsibility for their care as well as to highlight the need for systemic changes in the quality of care.
Nancy Conrad
C-Founder and Co-Chairman of Fundraising
The Community Emergency Healthcare Initiative
10:00-10:15 am
Break
10:15-11:30 am
Plenary
Patient Safety Fridays - QPS Management, Improvement and Culture Change
This presentation will take an in-depth review of how a leading healthcare system dedicates every Friday to patient safety education and then conducting tracers. The system mandates training of 1,400 managers across 5 sites to participate in activities encompassing various levels of involvement from physicians. Learn about the obstacles encountered, the challenges from staff in terms of patient safety, the need for a unified way for implementation, and the ultimate positive return on investment as well as well as sustaining a level of commitment. The organization developed the "Patient Safety Fridays" initiative to achieve the goal of becoming a High Reliability Organization. The objective of Patient Safety Fridays is to build an innovative process through which a culture of safety is promulgated, best practices are standardized and communicated across a large healthcare organization and staff share a common high level of knowledge on quality and patient safety issues.
Eliot J. Lazar, MD, MBA
Chief Quality Officer
New York Presbyterian Healthcare System
11:30-12:45 pm
Closing With Inspiration – Looking Ahead
Amazed & Amused: How to Survive and Thrive as a Healthcare Professional
Success is not measured only in dollars and cents, but also in the moments that you live amazed and amused. Balance is achieved not by see-sawing between opposites, but by accepting your place in the scheme of things, and by seeing it all as amazing and/or amusing. Surviving without thriving is not good enough, and we can only do our best when we self-create an attitude of amazement, and a perspective that encourages amusement. Bestselling author, RN, and observer of the human condition Karyn Buxman will take you on a life-changing journey of humor and hope.
Karyn Buxman, RN, MSN, CSP, CPAE
Founder, The HumorLab and Comedian
12:45 pm
Closing Comments/Adjourn
Peter B. Angood MD, FRCS(C), FACS, FCCM