JOINT COMMISSION RESOURCES EDUCATION

The Joint Commission Annual Conference on Quality and Safety Paper Titles and Abstracts

Meta-Leadership for Patient Safety: Building System Connectivity–An Interactive Workshop
Leonard J. Marcus, Founding Co-Director, National Preparedness Leadership Initiative, A Joint Program of the Harvard School of Public Health and Kennedy School of Government
Meta-Leaders leverage and expand health care capacity by strategically linking people, information, expertise, and knowledge. The session presented the concepts and practice of meta-leadership and illustrated how to build system connectivity for patient safety. The session consisted of an interactive workshop to problem solve meta-leadership solutions to become proactive.

The 2009 National Patient Safety Goals
Louise Kuhny, Senior Associate Director, Standards Interpretation, The Joint Commission
The session provided an overview of the Joint Commission’s National patient Safety goals and related requirements. The session focused the major challenges that health care organizations and The Joint Commission face in seeking to overcome barriers to success. Strategies for implementing the 2008 and 2009 NPSGs and requirements were presented.

Presidential Overview–The Joint Commission’s Role in Quality and Safety
Mark Chassin, President, The Joint Commission
This presentation focused on the latest agenda on The Joint Commission’s vision of integrating performance improvement activities to crate a safer health care industry.

Leadership for Quality and Patient Safety
Paul Levy, President and CEO, Beth Israel Deaconess Medical Center
When Paul Levy became CEO of the Beth Israel Deaconess Medical Center in 2002, he took over a troubled organization in serious financial difficulty. The presentation described how he took charge of a troubled organization and began the turnaround process by focusing on quality, safety, and sustained improvements. It also described leadership styles, management philosophies, the process dilemma, and the importance of communications strategies in decision making.

The Standards. Your Access. Your Way.
Sara Randall, Software Product Manager, Joint Commission Resources
This presentation showcased the new E-dition online database and the powerful new Accreditation Manager Plus electronic toolkit.

The State and Direction of Patient Safety and Culture… or If-Then
Stephen Harden, President, Lifewings Partners
This presentation focused on creating a better environment for physicians to help improve patient satisfaction. It also demonstrated how by creating a better work environment for nurses and staff, it would improve employee satisfaction, create less nurse turnover, and lower replacement and agency costs. Lastly, it highlighted how less errors by care givers led to improved patient satisfaction which in turn leads to improved market share.

Leading Health Care to a Safer Place (for Patients)
Deborah Nadzam, Practice Leader, Patient Safety Solutions, Joint Commission Resources
Christopher Durovich, President and CEO, Children’s Medical Center Dallas
Leadership is necessary to establish a culture of safety in health care organizations. This briefing highlighted 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, were presented.

Condition H: Partnering with Patients and Families
Amanda Fritz, Process Improvement Specialist
University of Pittsburgh Medical Center, Presbyterian Campus
Laurie Rack, Clinical Director, Patient Support Services, University of Pittsburgh Medical Center, Presbyterian Campus
Without effective communication, families and patients may feel their questions or concerns are being ignored or not addressed. UPMC Presbyterian’s began the patient safety initiative, Condition “Help” to assist patients and families to communicate when something is not right with their medical care. Participants learned how the plan can be applied to their health care organizations.

Medication Reconciliation Across an Integrated Health System
Steven Meisel, Director of Medical Safety, Fairview Health Services
Nancy Dimunation, Chief Nursing Officer, Fairview Red Wing Medical Center
This presentation discussed how Fairview achieved full medication reconciliation system-wide, reducing reconciliation-related errors and potential adverse drug events.

Fire Risk Assessment: A Score for Patient Safety
Kenneth Silverstein, Chair, Dept. of Anesthesiology, Christiana Care Health System
Judy Townsley, Director of Clinical Operations, Perioperative Services, Christiana Care Health System
Denise Dennison, Staff Development Specialist, Christiana Care Health System
The authors presented data that approximately 100 fires occur in operating rooms annually. They demonstrated how Christiana Care Health System sought to improve their approach to fire safety during surgical procedures. A comprehensive and reliable approach to surgical fire prevention was implemented after examining existing protocols. They also presented a fire risk assessment tool they developed that could be used in standard operations at other health care organizations.

Mayo Emergency Department Leans on Allergy Bands for Improved Patient Safety
Vernon Smith, Consultant, Department of Emergency Medicine, Mayo Clinic
Lori Scanlan-Hanson, Continuous Improvement Specialist, Department of Emergency Medicine, Mayo Clinic
The discussion focused on Mayo’s ED process improvement project to improve the efficiency, effectiveness, and safety of patient care through lean improvement methodology. Staff-based teams created state process maps and identified key improvement action plans within their goal of allergy bands. The teams succeeded in defining the appropriate place in the care process for applying allergy bands and setting accountability standards, eliminated the manual and non-value added steps of the process, and created a way to print bands so they are legible and consistent with an electronic allergy module.

Screening and Implementation of a DVT Prophylaxis Program for Medical/Surgical Population in an Acute Care Setting
Mary Foscue, Assistant Vice President of Medical Affair, Sacred Heart Hospital
Hella Ewing, Administrative Director Women Services/NICU, Sacred Heart Hospital
The presentation provided information on assisting acute care hospitals in implementing a screening/prophylaxis program for VTE by focusing on the facts, individual risk, and patient population risk. The presentation reviewed the methods of educating staff (pharmacy, nursing, and physician) on risk factors and appropriate prophylaxis and methods and tips for educating staff at other organizations

Patients at Risk of Suicide: Documenting the Suicide Risk Assessment and Treatment Plan
Jeffery Young, Medical Director of Regional Adult Behavioral Health Services, Providence Health
Brenda Anderson, Providence Health
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, there are no reliable quantitative tools for assessing risk, and there is no universally accepted definition of an adequate suicide risk assessment. This presentation reviewed the efforts of Providence Health to develop a consistent approach for documenting both the risk assessment and the treatment plan.

Public Disclosure of Healthcare Associated Infections and Reporting: Succeeding at the National Consensus Standards, Infection Control
Neil Fishman, Associate Professor of Medicine, Division of Infectious Diseases, University of Pennsylvania
Dr. Fishman brought 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. Other topics discussed were patterns and trends and tips for ongoing improvements.

Policies to Ensure Communication and Patient Safety - A Standardized Approach
Kristin Styer, Quality Program Manager, Perioperative Nursing, Brigham and Womens Hospital
The presentation discussed BYU’s standardized approach to hand off communication among care providers when a patient is transferred from one setting to another. BYU 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.

Tracing for Excellence: Safer Patients and Larger Savings for Healthcare
Judy Webber, Manager, Quality Resources, Immanuel St. Joseph's - Mayo Health System
Tamara Merchlewitz, Director, Organizational Learning, Immanuel St. Joseph's - Mayo Health System
Participants listened to how this organization improved its compliance with National Patient Safety Goals (NPSGs) and other Joint Commission standards by performing internal mock tracers to identify safety concerns before they reached the patient. In addition, internal tracers showed an improved level of preparedness in meeting NPSGs and Joint Commission standards. The organization emulated the tracer experience that The Joint Commission uses to ensure that staff always had safety at the top of their priorities.

Pediatric Patient Safety
Francine Westergaard, Consultant, Joint Commission International, Joint Commission Resources
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. The presentation discussed 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 organizations.

When An Error Happens You Can Do Three Things
Nancy Conrad, Co-Founder and Co-Chairman of Fundraising, The Community Emergency Healthcare Initiative
Ms. Conrad's interest in patient safety began as a result of the death of her late husband, astronaut Charles "Pete" Conrad. Although his life was spent in programs based on systems excellence, he died the preventable death of a systems failure. Ms Conrad's compelling story served to personalize the need for patients and their families to take responsibility for their care as well as highlighted the need for systemic changes in the quality of care.

Patient Safety Fridays - QPS Management, Improvement and Culture Change
Eliot J. Lazar, Chief Quality Officer, New York Presbyterian Healthcare System
This presentation reviewed how a leading healthcare system dedicates every Friday to patient safety education and to conducting tracers. The presenter discussed 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.

Amazed & Amused: How to Survive and Thrive as a Healthcare Professional
Karyn Buxman, Founder, The HumorLab and Comedian
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 took participants on a life-changing journey of humor and hope.