Everywhere. Safe Care. Pre-Conference Agenda. Conference Agenda. 8 8:30 a.m. Registration

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1 Safe Care. Everywhere Oct , 2014 mnpatientsafety.org Minneapolis Marriott Northwest, Brooklyn Park Pre-Conference Agenda 8 8:30 a.m. Registration 8:30 a.m. Noon Keeping Older Adults Active, Independent and Safe from Falls Deb Grimm, RN, Lake Region Healthcare, Fergus Falls, MN; Jane Larson, RN, BSN, Mille Lacs Health System, Onamia, MN; Corrine Neisess, RN, Lakewood Health System, Staples, MN; Jon Roesler, MS, Minnesota Department of Health, St. Paul, MN Noon 1 p.m. Lunch Falls are the #1 cause of unintentional injury deaths for Minnesotans age 65 and older. Gather your community partners (e.g., hospitals, long-term care organizations, community education, EMTs) to learn strategies from state partners and community falls pilot sites to successfully implement and prevent falls, fall-related injuries and maintain physical and cognitive functioning for Minnesota s older adults in any setting. 1 4:30 p.m. Creating a Just Culture: A Collaborative Approach to Better Outcomes Scott Griffith, partner, principal collaborator, SG Collaborative Solutions, LLC, Westlake, TX; John Overton, MD, cardiothoracic vascular surgeon, Hopkins, MN Conference Agenda Whether you are getting started or refreshing stalled efforts to create a safe and just culture in your organization, this session will help you understand the common barriers and key factors for success when changing culture to obtain better outcomes. Griffith will present a new way of thinking for health care improvement, explaining why traditional approaches, even those from high reliability organizations in other industries, may not yield the results expected. A more nuanced understanding of complex systems and human behaviors is needed and the secret to putting all this together lies in collaboration. 7:30 8:30 a.m. Registration 8:30 8:40 a.m. Welcome and Opening Remarks 1

2 8:40 9:40 a.m. Opening Keynote Address A Bold New Approach to Health Care Improvement Through Collaboration Scott Griffith, partner, principal collaborator, SG Collaborative Solutions, LLC, Westlake, TX Scott Griffith, founding partner and principal collaborator of SG Collaborative Solutions, LLC, will explain why traditional approaches, even those from high reliability organizations in other industries, may not yield the results expected. Captain Griffith will present a dramatic new way of thinking for health care improvement, calling for leveraged regulatory oversight, better labor-management relations, and provider organizations embracing a more advanced, socio-technical approach to managing risk. 9:45 10:45 a.m. General Session Adverse Events in Minnesota: Impact of Engagement, Communication & Transparency a Panel Discussion Patient panelists: Susan Johnson, Minneapolis, MN and Vonda Vaden Bates, Minneapolis, MN; Provider panelist: Margo Bowman, PharmD, MS, pharmacy administration resident, University of Minnesota Medical Center, Fairview, Minneapolis, MN 10:45 11:10 a.m. Break Hear perspectives and lessons learned from a health care professional and patients whom have experienced an adverse event. Learn how the event impacted the patient, provider, and how the organization responded to prevent these types of safety events from occurring in the future. 11:10 a.m. 12:10 p.m. Breakout Sessions #1 A Leader s Perspective: Lessons Learned from Implementing A Patient/Family-Centered Culture Chuck Hofius, chief executive oficer, Perham Health, Perham, MN 12:10 1:10 p.m. Lunch Be inspired to take risks and change the culture of your facility in ways that benefit everyone from the patient to the trustee. This session will provide practical advice and lessons learned during their journey on effectively partnering with patients and families while improving quality and safety outcomes. #2 Transforming Culture by Implementing a Falls Reduction and Relationship Program Shelly Wiggin, administrator, and Jean Jorlett, quality improvement and quality coordinator, Minnesota Masonic Home, Bloomington, MN In 2008, Minnesota Masonic Home embarked on a falls reduction program which dramatically reduced resident falls. This session will include highlights on setting clear expectations for staff, establishing an evidence-based performance culture, and building relationships with patients, families and the health care team. For more than six years the facility has maintained exemplary results and improved relationships across the organization with their falls program, Caring from the Heart Relationship Matters. #3 Delayed Diagnosis, Misdiagnosis and Missed Diagnosis: An Analysis and Recommended Prevention Strategies Laurie Drill-Mellum, MD, MPH, CMO, VP, patient safety solutions, MMIC, Minneapolis, MN Diagnostic errors in ambulatory health care settings are twice as frequent as errors caused by medical and surgical treatment, but they are harder to define, detect and measure. In addition, many physicians are unaware of cognitive biases that can adversely affect their day-to-day clinical decision-making. This presentation addresses these biases, plus other factors contributing to diagnostic failure, and presents strategies to minimize their impact. #4 Protecting Patients: Engaging Patients and Families in End-of-Life Care Decisions to Ease Transitions Heidi Meyers, RN, BSN, MBA/HCM, system advance care planning coordinator, Fairview Health Services, Minneapolis, MN Advance care planning (ACP) offers patients the opportunity to make decisions about future health care decisions in order to prevent unnecessary or unwanted cares. A well-thought out and honored health care directive can eliminate actual harm and/or immediate jeopardy to the patient by clearly outlining the types of treatments and/or transitions preferred. Physical and psychological harm can be avoided for the patient and their loved ones when ACP is handled well. Meyers will share how Honoring Choices Minnesota is working to standardize ACP throughout the state and give examples of the progress being made in Minnesota health care systems. 2

3 1:15 2:15 p.m. Breakout Sessions #5 Preventing Delirium Across the Settings of Care Sue Bikkie DNP, GNP, GCNS, APRN, BC, Orr & Associates, Mendota Heights, MN; Teresa McCarthy, MD, dept. of family medicine & community health/medical school, University of Minnesota, Minneapolis, MN 2:15 2:40 p.m. Break Delirium is a prevalent problem in hospitals and long-term care facilities. Delirium is associated with numerous negative outcomes including increased morbidity and mortality. Despite its clinical importance, delirium often goes unrecognized. Learn and discuss strategies for early detection, prevention and management of delirium within hospital and long-term care settings. #6 Preventing Violence in Health Care Settings John Brose, MD, Associated Clinic of Psychology, Minneapolis, MN Dealing with challenging patients/residents and family members/visitors in a variety of health care settings is often difficult. This session will include clinical and practical interventions as well as tips on how to protect staff, visitors and other patients/residents. Brose will include suggestions on how to take proactive steps to minimize the occurrence of violence between patients/residents and between patients/residents and their caregivers. #7 Analysis and Learnings From 10 Years of Adverse Event Reporting John Olson, PhD, professor, University of St. Thomas, St. Paul, MN; Diane C. Rydrych, director, division of health policy, Minnesota Department of Health, St. Paul, MN 2013 marked the 10-year anniversary of Minnesota s Adverse Health Events Reporting System. The system was designed to facilitate improved safety in the health care system through information sharing, transparency and learning in a non-punitive environment. Dr. Olson will highlight findings from review of the 10 years of data and the impact the reporting has made to ensure patients receive the best care possible. #8 More Than a Conversation: Patient Engagement and Decision-Making David Shute, MD, medical director, Greenfield Health, Portland, OR The Choosing Wisely Campaign is a national effort to reduce potential harm that comes from unnecessary tests and procedures. At the core of the campaign is shared decision-making between the health care provider and the patient. This presentation will provide the current research on patient engagement, skills that support effective communication and practical solutions to common challenges. 2:40 4 p.m. General Session and MAPS Awards The Heart and Soul of Patient Care Allison Massari, speaker, executive coach, artist, Navato, CA Allison Massari has intimate experience with the health care industry as a patient and as an educator. She knows first-hand the transforming power of personalized care provided by committed professionals. The survivor of a horrifying and fiery car crash, followed by more than 400 days in hospitals, doctors offices and physical therapy, Allison brings a fresh, relevant perspective to this session. Let her personal story of triumph over tragedy move you to a better understanding of the importance of patient-centered care. 8:30 9:45 a.m. General Session Making the Connection Between Employee Resiliency and Patient Safety J. Bryan Sexton, PhD, associate professor in psychiatry, Duke University, Durham, NC Participants will experience an entertaining, rewarding and validating presentation on the importance of employee resiliency and the connection between health care worker capacity for change and quality improvement efforts a.m. Breakout Sessions #9 Sepsis Across Community Settings: Lessons Learned Dawn Tomac, RN, CIC, director of quality and safety, Avera Health, Sioux Falls, SD; JoAnn Coover, RN, infection prevention, Avera Marshall Regional Medical Center, Marshall, MN Severe sepsis can be associated with a mortality rate of up to 50%. The Minnesota Hospital Association s Leading Edge Advanced Practice Topics (LEAPT) project has coordinated the development of a Seeing Sepsis tool kit to facilitate early detection and treatment of sepsis in hospitals. Tomac will talk about the application of Seeing Sepsis tools to non-hospital settings, primarily long-term care. 3

4 11 11:15 a.m. Break #10 Dealing With Multi-Drug Resistant Infections Across Care Settings Candice Shearen, RN, director of education, Welcov Healthcare, Edina, MN; Stephanie Tismer, RN, BSN, CIC, president, APIC MN Learn how multi-drug resistant infections occur across all settings of care and how to deal with them. This session will review actions that work and those that don t. Communication and teamwork across all settings is key. #11 Learning From Every Death: A Journey to Improved Transparency, Learning and Results Timothy Morgenthaler, MD, patient safety officer, and Jeanne Huddleston, MD, internal medicine, Mayo Clinic, Rochester, MN Careful systematic review of the care received by patients who expire in acute care hospitals reveals rich, actionable information leading to opportunities, not only for provider practice improvements and enhanced team building, but also for strategic system strategies that combined lead to improved patient safety and outcomes. In this session, you will gain understanding of how mortality review leads to insights regarding patient care, how the analysis can lead to system changes and lessons learned from the mortality review process. #12 Ensuring Safety at Transitions of Care: Lessons from Consumer Research and Pilot Testing Marie Dotseth, executive director, Minnesota Alliance for Patient Safety, Minneapolis, MN The Minnesota Alliance for Patient Safety (MAPS) recently received a grant to focus on what consumers can do at transitions of care to reduce errors and improve safety. A consumer-focused campaign was developed and tools to help prevent harm at transitions of care were produced and tested. This session will describe the research, campaign and results of the pilot testing and show how patients/residents/families/consumers can protect themselves from medical errors, especially during times of transition. 11:15 a.m. 12:15 p.m. Breakout Sessions #13 Pharmacy Residents Reduce Drug Therapy Problems Across Settings of Care Todd Sorenson, PharmD, and Andrea Rosenberg, PharmD, University of Minnesota, Minneapolis, MN 12:15 1:15 p.m. Lunch Adverse drug events are one of the most frequent adverse events, especially during transitions of care. In this session you will learn how the MHA Partnership for Patients is addressing medication safety across the continuum of care and how pharmacy residents are improving transitions in care by establishing mechanisms for comprehensive medication management evaluations with patients within seven days of post-acute care discharge. #14 Taking a Deeper Dive into Employee Resiliency Tools and Techniques J. Bryan Sexton, PhD, associate professor in psychiatry, Duke University, Durham, NC In follow-up to the general session, participants will experience laughter, joy and recharging nearly dead batteries as they learn and practice effective techniques to address and manage fatigue, burnout and coping with change. #15 Mandatory Flu Shots for Employees: Minnesota Experience Kristin Royer, MPH, director, infectious disease epidemiology, Minnesota Department of Health, St. Paul, MN; Lisa Ide, MD, MPH, occupational medicine specialist, University of Minnesota Medical Center, Fairview, Minneapolis, MN There is increasing interest in policies that mandate influenza vaccines for health care workers. This session will provide an overview of the state of health care worker vaccination and describe the experiences of two health systems in this venture. #16 Health Information Technology and Safety Candy Hanson, program manager, Stratis Health, Bloomington, MN Interoperable health information exchange will transform the health care industry. Learn about a special innovation project that Stratis Health led called Health Information Technology for Post Acute Care (HITPAC). Learn the value of interoperable health information exchange and how it can be used to improve safety and outcomes in health care. 1:15 2:15 p.m. Breakout Sessions #17 Meaningfully Engaging Physicians With Patient Safety Leslie Anderson, MPA, chief of staff, University of Minnesota Medical School, Minneapolis, MN Through the Partnership for Patients LEAPT, MHA is working with the University of Minnesota Medical School to engage physician residents in quality improvement and patient safety initiatives. In this session you will learn how the future generation of physicians are being educated and engaged to prevent pressure ulcers. 4

5 2:15 2:30 p.m. Break #18 When to Hold Em and When to Fold Em Val Ulstad, MD, MPH, MPA, partner, Cascade Bluff, Minneapolis, MN Destructive behavior is exhausting and it is a signal. It is a signal of distress in an individual and it may point to something important to address in the organizational culture. A compassionate and curious approach is needed first. After we have done what we can to help a person make progress, we must be ready to act with courage, consistency and clarity. #19 Best Practices to Prevent Drug Diversion in Health Care Organizations Keith Berge, MD, anesthesiologist, Mayo Clinic, Rochester, MN; Shelley Matthes, senior director of QA and resources utilization, Ecumen, Duluth, MN The Roadmap Resource for Controlled Substances Diversion Prevention was unveiled in 2012 by the Minnesota Hospital Association, the Minnesota Department of Health and 20 coalition members. This roadmap, with over 100 best practices for prevention and responding to substance diversion, has served as a guide to hospitals and care centers. Learn from two health systems about their experience and lessons learned. #20 RARE and Beyond Kathy Cummings, RN, MA, project manager, Institute for Clinical Systems Improvement, St. Paul, MN; Kim McCoy, program manager, Stratis Health, St. Paul, MN; Kattie Bear-Pfaffendorf, MBA, patient safety/quality specialist, Minnesota Hospital Association, St. Paul, MN The Reducing Avoidable Readmissions Effectively (RARE) campaign operating partners will describe what the RARE campaign was and share the RARE Campaign evaluation and outcomes. The operations partners will discuss what is next for the RARE campaign and facilitate a discussion with attendees of the community opportunities and strengths for care coordination. 2:30 3:30 p.m. Closing Keynote Session Facing Reality and Remaining Hopeful Val Ulstad, MD, MPH, MPA, partner, Cascade Bluff, Minneapolis, MN 3:30 p.m. Adjourn The chance to be more intentional and effective in our leadership is everywhere. To actualize our vision of safe care everywhere, requires seeing opportunities to use ourselves more effectively everywhere. This closing session will focus on how we can consistently mobilize others through our exercise of leadership every day wherever we find ourselves. Conference Information About the conference Safe Care: Everywhere is the seventh conference sponsored by the Minnesota Alliance for Patient Safety (MAPS) since The 2014 MAPS Conference will disseminate leading edge practices, provide knowledge on critical topics in safe care and facilitate creative and solution-oriented dialogue about how to make health care sustainable and measurably safer in Minnesota. Objectives Recognize trends in safe care to improve safety across health care settings; Provide strategies and actions for establishing and maintaining a culture of safety; Demonstrate how organizations have successfully measured the outcomes of their patient safety improvement initiatives; Provide creative and solution-oriented initiatives on making health care safer and sustainable everywhere. Who should attend Health care professionals, quality and safety leaders, managers, educators and others interested in patient safety across all health care settings. Registration Registration information about the patient safety conference can be found at You may register for this program in any of the following ways: By mail: download the registration form at mnpatientsafety.org/events/2014-conference and mail to: MAPS Conference c/o Minnesota Hospital Association 2550 University Ave. W., Ste. 350-S Saint Paul, MN By fax: (651) Online: visit login and click on Calendar of Events to register. 5

6 Registration fee (does not include lodging accommodations) Pre-conference fees for Oct. 22: the pre-conference fee is $75 per person for one half-day session or $135 for a fullday (2 sessions). Before Sept. 13 for Oct $295 MAPS members $345 Non-members Students: $50 per day After Sept. 12 for Oct $425 Conference registration fee for all attendees Students: $50 per day The fee reflects the cost of program development, administration, promotion, faculty expenses, lunch, and break items. MAPS reserves the right to cancel or reschedule due to an insufficient number of registrants or other unforeseen circumstances. Registration will be accepted on a first-received basis. Registration fees, less a $25 cancellation fee are refundable if notice is received five working days prior to the program date. Registrants unable to attend may send one alternate. No show registrations will be billed. Space is limited! Special needs If you have any special needs that we can accommodate for this program, please contact MHA s Education Department at (651) prior to the event. Sponsors Accommodations To make reservations, please call the Minneapolis Marriott Northwest directly at (877) or (763) , or book your room at the group rate online. Please indicate that you are attending the MAPS Conference when making overnight accommodations. Room rate: $129 standard suite; Cut-off date: Oct. 3, Continuing education opportunities Nurses Contact Hours: This activity has been designed to meet the Minnesota Board of Nursing continuing education requirements. A total of up to 20.5 contact hours will be awarded to those attending this educational activity. However, the nurse is responsible for determining whether this activity meets the requirements for acceptable continuing education. (Pre-conference 7.8; Day One 6.4; Day Two 6.3). Pharmacists: 17 contact hours have been approved through the Minnesota Board of Pharmacy. Pharmacists must complete a CEU and program evaluation form at the conclusion of the conference. Official certificates of continuing education will be mailed to attendees after the program. (Pre-conference 6.5; Day One 5.25; Day Two 5.25). Long-Term Care Administrators: 17 Continuing Education Units have been approved from the Minnesota Board of Examiners for Nursing Home Administrators. (Preconference 6.5; Day One 5.25; Day Two 5.25). 6

7 Minnesota Alliance for Patient Safety 2014 Conference Safe Care. Everywhere Name: Title: Facility/Organization: Address: City: State: Zip: Phone: Fax: Method of Payment c Check made payable to MAPS enclosed c VISA c MasterCard c American Express Card number: Expiration date: Sec. code (3 digit number on back of card: Name on card: If you plan to attend the Wednesday, Oct. 22 pre-conference sessions, please indicate which sessions you will attend. c Keeping Older Adults Active, Independent and Safe from Falls (8:30 a.m. Noon) c Creating a Just Culture: A Collaborative Approach to Better Outcomes (1 4:30 p.m.) Please indicate which breakout sessions you will be attending (check one per time slot) Thursday, Oct. 23, :10 a.m. 12:10 p.m. Breakout Sessions c #1 A Leader s Perspective: Lessons Learned from Implementing A Patient/Family-Centered Culture c #2 Transforming Culture by Implementing a Falls Reduction and Relationship Program c #3 Delayed Diagnosis, Misdiagnosis and Missed Diagnosis: An Analysis and Recommended Prevention Strategies c #4 Protecting Patients: Engaging Patients and Families in End-of-Life Care Decisions to Ease Transitions 1:15 2:15 p.m. Breakout Sessions c #5 Preventing Delirium Across the Settings of Care c #6 Preventing Violence in Health Care Settings c #7 Analysis and Learnings From 10 Years of Adverse Event Reporting c #8 More Than a Conversation: Patient Engagement and Decision-Making Friday, Oct. 24, a.m. Breakout Sessions c #9 Sepsis Across Community Settings: Lessons Learned c #10 Dealing With Multi-Drug Resistant Infections Across Care Settings c #11 Learning From Every Death: A Journey to Improved Transparency, Learning and Results c #12 Ensuring Safety at Transitions of Care: Lessons from Consumer Research and Pilot Testing 11:15 a.m. 12:15 p.m. Breakout Sessions c #13 Pharmacy Residents Reduce Drug Therapy Problems Across the Settings of Care c #14 Taking a Deeper Dive into Employee Resiliency Tools and Techniques c #15 Mandatory Flu Shots for Employees: Minnesota Experience c #16 Health Information Technology and Safety 1:15 2:15 p.m. Breakout Sessions c #17 Meaningfully Engaging Physicians With Patient Safety c #18 When to Hold Em and When to Fold Em c #19 Best Practices to Prevent Drug Diversion in Health Care Organizations c #20 RARE and Beyond

8 You may register for this program in any of the following ways: Mail to: Minnesota Hospital Association 2550 University Ave. S., Ste. 350-S St. Paul, MN Fax: (651) Online: Visit login and click on Calendar of Events to register. Registration Fee (does not include lodging accommodations) Pre-Conference Fees for Oct. 22: $75 per person for one half-day or $135 for a full-day. (2 sessions) Before Sept. 13 for Oct : MAPS members: $295 Non-members: $345 Student: $50 per day After Sept. 12 for Oct : $425 for all attendees Student: $50 per day 7514