HRO and Dx. High Reliability and Diagnosis. Mark Graber and Michael Crossey. Panel 1 // March 6, 2014 // 2:30-3:45 pm 7/2/2014
|
|
- Maude Gardner
- 6 years ago
- Views:
Transcription
1 HRO and Dx Mark Graber and Michael Crossey High Reliability and Diagnosis Panel 1 // March 6, 2014 // 2:30-3:45 pm Attaining High Reliability and Safety for Patients Collaborating for Change. Patient Safety Collective of the Southwest (PSCS). March 6-7, 2014; Albuquerque, NM 1
2 Diagnosis and High Reliability Mark L Graber MD FACP Senior Fellow, RTI International Professor Emeritus, SUNY Stony Brook School of Medicine Founder and President, Society to Improve Diagnosis in Medicine Michael J Crossey MD PhD Executive Medical Director, TriCore Reference Laboratory CE Disclosure In compliance with the ACCME/NMMS Standards for Commercial Support of CME Mark Graber MD FACP has been asked to advise the audience that he has no relevant financial relationships to disclose or does have relevant financial relationships to disclose which he will disclose here. Attaining High Reliability and Safety for Patients Collaborating for Change. Patient Safety Collective of the Southwest (PSCS). March 6-7, 2014; Albuquerque, NM 2
3 Diagnosis and High Reliability Is diagnosis a high reliability process? What is the reliability of diagnostic support services - The clinical lab and radiology? How can diagnosis achieve higher levels of reliability? Adapting High Reliability Science to Healthcare Leadership commits to the ultimate goal of 0 patient harm Incorporation of all the best principles and practices of a safety culture throughout the organization Widespread adoption and deployment of the most effective process improvement tools and methods High Reliability Health Care Getting There from Here. MR Chassin and J Loeb. Milbank Quarterly :
4 Demonstrating High Reliability on Accountability Measures at The Johns Hopkins Hospital. Pronovost et al. Jt Com Jl Qual Pt Safety Dec 2013 Diagnosis is HARD! PATIENT VARIABLES Stage of disease How it manifests How it is perceived How it is described When help is sought SYSTEM COMPLEXITY Disjointed care Communication barriers Production pressure Tight coupling Access to care & expertise PHYSICIAN VARIABLES Knowledge and experience Access to patient data, tests, consults Skill in clinical reasoning Stress, distractions, mood, time to think 4
5 How Many Diseases are There? World Health Organization: ICD ICD ICD ? ICD ,420 NLM: 8000 MESH terms Growing at 200+/year Estimates of the Diagnostic Error Rate Expert guess Arthur Elstein: 10-15% Patient Surveys Second reviews Standard Patients Look backs Chart review Autopsies One third of patients relate a Dx error that affected themselves, a family member, or close friend Radiology: 10-30% of breast cancers missed Pathology: 1-2% of cancers misread Internists misdiagnosed 13% of patients presenting with common conditions to clinic (COPD, RA, others) Dissecting AAA: 39% delayed diagnosis Cervical cancer: 25-50% of last nl PAP are abnl 1 visit/1000 associated with a dx error and the likelihood of serious harm Major unexpected discrepancies that would have changed the management are found in 10-20% 5
6 US The toll of Dx Error Your Hospital 40,000 80,000 deaths/yr 1 in 1000 primary care visits involves a preventable dx error causing harm Error-related Harm 10 deaths every year 1 patient harmed every other day in your clinics or ER Diagnostic Error Leape et al. JAMA 288:2405, 2002 Singh et al. BMJ Qual Safety 21: , 2012 Root Causes of Diagnostic Error 100 cases 535 root causes Graber et al. Arch Int Med 165:1493-9, 2005 BLUNT end SYSTEM Communication, coordination, training, policies, procedures, access to expertise SHARP end Me Patient s Clinical Course Cognitive 6
7 Error in the Diagnostic Process DIAGNOSTIC ERROR (Wrong, missed & delayed diagnosis) No Fault Causes Silent disease Too early; atypical Patient misleads us Patient doesn t f/u Inconsequential HARM History Physical Exam Hypotheses, Synthesis Tests, Consults Follow Up HARM 7
8 Breakdowns in the Diagnostic Process Process Step Incidence of Errors Dx testing (lab and radiology) 44% Assessment 32% H&P 10% Referral and consultation 10% Follow-up 10% Schiff et al. 2009; Diagnostic Error in Medicine - Analysis of 583 physician-reported erros. Archives Int Med 169: High Reliability Someone owns the process The pieces are integrated Top priority is safety Equivalent actors Performance is predictable Measurement is king Culture: Resilient, safety oriented Results: Six Sigma Diagnosis No one owns the process Independent systems Top priority is fiscal responsibility Independent actors Performance is variable Measurement doesn t exist Culture: Results: One or Two Sigma** DIAGNOSTIC ERROR RATE Medicine, Peds, ER: 10% Radiology: 2-4% Clinical Lab: Analytical phase: Pre- and Post-analytical phases: <0.001% errors 10% errors 8
9 Diagnostic Error: Reducing Its Impact Through Improving Reliability t r i c o r e. o r g CE Disclosure In compliance with the ACCME/NMMS Standards for Commercial Support of CME Michael Crossey MD PhD has been asked to advise the audience that he has no relevant financial relationships to disclose or does have relevant financial relationships to disclose which he will disclose here. Attaining High Reliability and Safety for Patients Collaborating for Change. Patient Safety Collective of the Southwest (PSCS). March 6-7, 2014; Albuquerque, NM 9
10 A) Correct Diagnosis = Correct Care B) Correct Care = Quality Care C) Quality Care + Safe, Efficient, Cost Effective tricore.org 19 Why The Laboratory? - Lab cost are low, 2-3% of Medicare spend % of diagnostic decisions are driven by laboratory results tricore.org 20 10
11 History Physical Exam Hypotheses, Synthesis Tests, Consults Follow Up Diagnostic Error Diagnosis How to keep patients safe in a complex environment? External Forces tricore.org 22 11
12 How to keep patients safe in a complex environment? Internal Forces tricore.org 23 How to keep patients safe in a complex environment? tricore.org 24 12
13 1) Simplify where we can 2) Integrate where we can t simplify tricore.org 25 Do s and Don ts tricore.org 26 13
14 The Lab Do Don t Simplify the lab ordering process disease state List every test by test name tricore.org 27 The Lab Do Don t Take ownership of the pre-analytic phase Maintain silos tricore.org 28 14
15 The Lab Do Don t Create interpretive reports Generate data tricore.org 29 As a System Do Don t Put patient safety as a line item on every Hospital Committee P&T, MIC, IC, CPC Create a new patient Safety Super Committee tricore.org 30 15
16 - Complex patient care requires a team effort - Team efforts require a shared goal with clearly defined strategy and tactics tricore.org 31 What can I do to reduce Dx error? Physicians, NP s, PA s Nurses Labs Healthcare organizations Patients Attaining High Reliability and Safety for Patients Collaborating for Change. Patient Safety Collective of the Southwest (PSCS). March 6-7, 2014; Albuquerque, NM 16
17 Sdkljfgaskjfha;hfas;dhfa s;dflknasd;lfksdfl kasdf lasdkjfas;djfasd l;fksld/ kfj asdjasd jasd Questions? Mark Graber: Michael Crossey: Attaining High Reliability and Safety for Patients Collaborating for Change. Patient Safety Collective of the Southwest (PSCS). March 6-7, 2014; Albuquerque, NM 17
General Session: Diagnostic Error in Medicine The Next Imperative for Patient Safety
General Session: Diagnostic Error in Medicine The Next Imperative for Patient Safety Speaker: Mark Graber Northland Ballroom Thursday, Oct. 27 2:40 3:40 p.m. Sponsored by: Mark L. Graber, M.D., FACP Mark
More informationADDRESSING DIAGNOSTIC ERROR
ADDRESSING DIAGNOSTIC ERROR Mark L. Graber, MD, FACP Founder and President SIDM Senior Fellow RTI International Professor Emeritus SUNY Stony Brook graber.mark@gmail.com Society to Improve Diagnosis in
More informationThe Role of the RN and APRN in Addressing Diagnostic Error
The Role of the RN and APRN in Addressing Diagnostic Error Mark L. Graber, MD, FACP Founder and President SIDM Senior Fellow RTI International Professor Emeritus Stony Brook University, NY graber.mark@gmail.com
More informationCharting the Course to
Charting the Course to Improved Medical Diagnosis Mark L Graber, MD FACP President, SIDM Senior Fellow, RTI International Disclosures: None Goals: Discuss.. The main findings of the IOM report: Improving
More informationImproving Diagnosis The New Imperative. Mark L Graber, MD FACP President, SIDM Senior Fellow, RTI International
Improving Diagnosis The New Imperative Mark L Graber, MD FACP President, SIDM Senior Fellow, RTI International 1 Society to Improve Diagnosis in Medicine VISION: We envision a world where diagnosis is
More informationA17/B17: Addressing Diagnostic Error: Creating Reliable Systems for Diagnosis and Tracking in Primary Care
A17/B17: Addressing Diagnostic Error: Creating Reliable Systems for Diagnosis and Tracking in Primary Care Gordy Schiff, MD, Associate Director of Brigham and Women s Center for Patient Safety Research
More informationFocus on Diagnostic Errors: Understanding and Prevention
Focus on Diagnostic Errors: Understanding and Prevention Tejal Gandhi, MD MPH CPPS President, National Patient Safety Foundation Associate Professor, Harvard Medical School Thanks to Dr. Mark Graber for
More informationAddressing Diagnostic Error: Creating Reliable Systems for Diagnosis and Tracking in Primary Care
Addressing Diagnostic Error: Creating Reliable Systems for Diagnosis and Tracking in Primary Care IHI Workshop 12/6/16 Gordon Schiff, MD, Associate Dir Brigham & Women s Ctr for Patient Safety Research
More informationAchieving safety in medication management through barcoding technology
Achieving safety in medication management through barcoding technology Kara Marx, RN, FACHE, FHIMSS Vice President of Information Services Sharp Healthcare. SESSION OBJECTIVES Describe the primary activities
More informationI would like to formally recognize those physicians receiving four or more tributes from their patients:
Doctors Day Program Doctors Day We received an overwhelming response and positive feedback from our 2015 Doctors Day Program. Since the inception of this program, 510 Upstate Physicians have been honored
More informationClick to edit Master title. style. Click to edit Master title. style. style 8/3/ Are You on Track?
Are You on Track? Diagnostic Test Results, Consults and Referrals Click to edit Master subtitle EXPLORE Conference August 9, 2018 8/3/2018 1 EXPLORE August 9, 2018 Today s speaker is Brenda Wehrle, BS,
More informationMedical-legal Issues in Pathology
Medical-legal Issues in Pathology Kathryn Reducka MD, Physician Risk Manager, CMPA Pathology Update 2015 Toronto, ON November 14, 2015 Faculty / Presenter Disclosure Faculty: Employee of: Dr Kathryn Reducka
More informationDiagnostic Errors: A Persistent Risk
Diagnostic Errors: A Persistent Risk Laura M. Cascella, MA The term medical error often conjures thoughts of wrong-site surgeries, procedures performed on the wrong patients, retained foreign objects,
More informationDisclosures. Platforms for Performance: Clinical Dashboards to Improve Quality and Safety. Learning Objectives
Platforms for Performance: Clinical Dashboards to Improve Quality and Safety Disclosures The program chair and presenters for this continuing pharmacy education activity report no relevant financial relationships.
More informationDiagnostic error in medicine: introduction
Adv in Health Sci Educ (2009) 14:1 5 DOI 10.1007/s10459-009-9187-x EDITORIAL Diagnostic error in medicine: introduction Eta S. Berner Published online: 11 August 2009 Ó Springer Science+Business Media
More informationCOOK COUNTY HEALTH & HOSPITALS SYSTEM
COOK COUNTY HEALTH & HOSPITALS SYSTEM CCHHS Board of Directors Quality and Patient Safety Committee Quality and Reliability in Health Care Krishna Das, MD, Chief Quality Officer 15 March 2016 Quality:
More informationPatient-Centered Medical Home (PCMH) & Patient-Centered Specialty Practice (PCSP)
Patient-Centered Medical Home (PCMH) & Patient-Centered Specialty Practice (PCSP) Foundation for a Better Health Care System Presenter Jeanette Ikan, M.D., MHAI Objectives: Definition and benefits of PCMH,
More informationFrom Risk Management to Action Addressing Diagnostic Error. Dr. Terrance Borman Dr. Joseph Britto
From Risk Management to Action Addressing Diagnostic Error Dr. Terrance Borman Dr. Joseph Britto Overview of presentation Luther Midelfort and our risk management Making the case for diagnostic error as
More information9/23/2015. Jackie F. Webb, DNP, FNP-BC Assistant Professor Linfield College
Jackie F. Webb, DNP, FNP-BC Assistant Professor Linfield College Participants will understand differences between traditional care vs. group care Participants will describe effective components of group
More informationThe Laboratorian as a Clinical Consultant
The Laboratorian as a Clinical Consultant Anthony A. Killeen, MD, PhD Professor and Vice-Chair Dept. of Laboratory Medicine & Pathology University of Minnesota April 25, 2018 Copyright 2016, Cardinal Health.
More informationSharp HealthCare s HRO Commitment
Sharp HealthCare s HRO Commitment Daniel L. Gross, DNSc, RN Executive Vice President Amy Adome, MD, MPH Senior Vice President, Clinical Effectiveness November 3, 2016 Perfection is not attainable, but
More informationHow Should Surgeons Deal With Other Surgeons Errors?
How Should Surgeons Deal With Other Surgeons Errors? John W. C. Entwistle III, MD PhD Associate Professor of Surgery Thomas Jefferson University April 25, 2015 Conflicts I have no conflicts relevant to
More informationAnatomy of a Fatal Medication Error
Anatomy of a Fatal Medication Error Pamela A. Brown, RN, CCRN, PhD Nurse Manager Pediatric Intensive Care Unit Doernbecher Children s Hospital Objectives Discuss the components of a root cause analysis
More informationRED SIGNAL REPORTSM RADIOLOGY. August 2018 Vol. 1 No. 1. Claims Data Signals & Solutions to Reduce Risks and Improve Patient Safety.
RED SIGNAL REPORTSM August 2018 Vol. 1 No. 1 Claims Data Signals & Solutions to Reduce Risks and Improve Patient Safety. RADIOLOGY MEDICAL LIABILITY INSURANCE BUSINESS ANALYTICS RISK MANAGEMENT & EDUCATION
More informationTranslational Safety Through Immersive Learning: Practice What you Preach
Translational Safety Through Immersive Learning: Practice What you Preach Gregory Botz, MD, FCCM Professor, Department of Critical Care Division of Anesthesiology and Critical Care The University of Texas,
More informationThe Pediatric Pathology Milestone Project
The Pediatric Pathology Milestone Project A Joint Initiative of The Accreditation Council for Graduate Medical Education and The American Board of Pathology July 2015 The Pediatric Milestone Project The
More informationDeveloping a Curriculum in Patient Safety and Quality Improvement for Your Clerkship
Developing a Curriculum in Patient Safety and Quality Improvement for Your Clerkship Diane Levine, Wayne State University Allison Heacock, The Ohio State University Amy Shaheen, University of North Carolina
More informationFrom Reactive to Proactive: Creating a Population Management Platform
Session D9 / E9 From Reactive to Proactive: Creating a Population Management Platform Richard Gitomer, MD Director, Brigham and Women s Primary Care Center of Excellence Vice Chair, Primary Care, Dept.
More informationPatient and Family Engagement to Prevent Diagnostic Error
Patient and Family Engagement to Prevent Diagnostic Error Martine Ehrenclou, MA Award-Winning Author, Healthcare Advocate Tejal Gandhi, MD MPH CPPS President National Patient Safety Foundation Kathryn
More informationTEXAS SOCIETY OF PSYCHIATRIC PHYSICIANS CME ACTIVITY DEVELOPMENT WORKSHEET
TEXAS SOCIETY OF PSYCHIATRIC PHYSICIANS CME ACTIVITY DEVELOPMENT WORKSHEET ACTIVITY: ACTIVITY DATE ACTIVITY LOCATION: (C7) NOTE ABOUT ACCME S SCS: PROVIDERS SHOULD REMEMBER TO INTEGRATE THE SCS INTO THEIR
More informationThe Quality, Safety, and Value Revolutions:
NPSF Professional Learning Series presents: The Quality, Safety, and Value Revolutions: Why Change is No Longer Elective January 7, 2014 Robert M. Wachter, MD Professor and Associate Chairman, Department
More informationPEDIATRIC PRIMARY CARE and BEHAVIORAL HEALTH INTEGRATION
PEDIATRIC PRIMARY CARE and BEHAVIORAL HEALTH INTEGRATION AN OASIS IN THE FUTURE James N Bowen DO Chief Medical Officer The Guidance Center Flagstaff, AZ. WHAT WE WILL DISCUSS Why? What? How? When? WHY
More informationPatient. Doctor. How Direct Primary Care Improves Health Care 4/3/2018. Direct Care. Disclosures. Direct Primary Care. Learning Objectives
Disclosures How Care Improves Health Care Nothing to disclose. LORI CARNSEW, MD FAAFP Learning Objectives Care 1. How is Care patient centered? 2. Can DPC reduce health care costs? 3. Can DPC help with
More informationPERFORMANCE MEASURE DATE / RESULTS / ANALYSIS FOLLOW-UP / ACTION PLAN
Resident-to-Resident Assaults AIM: To decrease incidents of Resident to Residents assaults by 5% in the Fiscal Year (FY) 2011-2012. MONITORING: Data is collected from all instances in which State of California
More informationTransitions of Care: An opportunity to improve care, experience and reduce waste
Transitions of Care: An opportunity to improve care, experience and reduce waste Dr. Paresh Dawda, Visiting Fellow, Australian Primary Health Care Research Institute, ANU Adjunct Associate Professor, University
More informationFrom Value to High-Reliability Organization
From Value to High-Reliability Organization William R Mayfield MD, FACS Chief Surgical Officer WellStar Health System ACS NSQIP Chicago July 2015 No disclosures Outline Origins of the High-Reliability
More informationQuality Improvement in the ICU: A Way Forward
Quality Improvement in the ICU: A Way Forward Ognjen Gajic M.D. Mayo Clinic Rochester MN, USA Multidisciplinary Epidemiology and Translational Research in Intensive Care, Emergency and Perioperative Medicine
More informationPatient Interview/Readmission Chart Review. Hospital Review:
Appendix: Readmission Review Form Patient Interview/Readmission Chart Review Patient Name: Previous Hospital Admission Date Account Number Previous Hospital D/C Date: D/C MD: Previous Hospital Discharge
More informationUnderstanding the High Reliability Organization and Why It's Important to Your Lab
Understanding the High Reliability Organization and Why It's Important to Your Lab Jennifer Rhamy MBA, MA, MT(ASCP)SBB, HP Executive Director, Laboratory Accreditation High Reliability Organization (HRO)
More informationDiagnosing the Diagnostic Dilemma
Session D12 / E12 This presenter has nothing to disclose Diagnosing the Diagnostic Dilemma Part Two Institute of Medicine Report and Recommendations and Beyond Gordon Schiff MD Wednesday, Dec 9 th 9:30
More informationThe Care Transitions Intervention
The Care Transitions Intervention Kimberly Irby, MPH Colorado Foundation for Medical Care www.cfmc.org/integratingcare Acknowledgments: Objectives To provide an overview of the Care Transitions Intervention
More informationU.S. Healthcare Problem
U.S. Healthcare Problem U.S. Federal Spending GDP (%) Source: Congressional Budget Office This graph shows that government has to spend a lot of more money in healthcare in the future and it is growing
More informationOn the CUSP: Stop BSI
On the CUSP: Stop BSI Learning From Defects December 6, 2011 Comprehensive Unit-based Safety Program (CUSP) 1. Educate staff on science of safety (www.safercare.net) 2. Identify defects 3. Assign executive
More informationAre National Indicators Useful for Improvement Work? Exercises & Worksheets
Session L5 These presenters have nothing to disclose These presenters have nothing to disclose Are National Indicators Useful for Improvement Work? Exercises & Worksheets Robert Lloyd, PhD Göran Henriks,
More informationRobert J. Welsh, MD Vice Chief of Surgical Services for Patient Safety, Quality, and Outcomes Chief of Thoracic Surgery William Beaumont Hospital
Robert J. Welsh, MD Vice Chief of Surgical Services for Patient Safety, Quality, and Outcomes Chief of Thoracic Surgery William Beaumont Hospital Royal Oak, Michigan, USA 1 ARE OUR OPERATING ROOMS SAFE?
More informationJoel S. Weissman, Ph.D. Mass. Gen. Hospital/Harvard Med. School Harvard Quality Colloquium. August 22, 2005
The Path Toward Achieving the IOM Goal of Transparency: What Do Hospital Executives Think about Reporting and Disclosure of Medical Errors? Joel S. Weissman, Ph.D. Mass. Gen. Hospital/Harvard Med. School
More informationPharmacists in Transitions of Care: We Can All Make a Difference
Pharmacists in Transitions of Care: We Can All Make a Difference Disclosure The speakers of this panel have no actual or potential conflict of interest in relation to this program to disclose. Kenda Germain,
More informationTransitions of Care: From Hospital to Home
Transitions of Care: From Hospital to Home Danielle Hansen, DO, MS (Med Ed) Associate Director, LECOM VP Acute Care Services & Quality/Performance Improvement, Millcreek Community Hospital Objectives Discuss
More informationReducing Delay in Diagnosis: Multistage Recommendation Tracking
Health Care Policy and Quality Original Research Wandtke and Gallagher Multistage Recommendation Tracking to Reduce Delays in Diagnosis Health Care Policy and Quality Original Research FOCUS ON: Ben Wandtke
More information10/23/2015. Don t drop the baton: Improving handover communication from the CMPA s perspective
Don t drop the baton: Improving handover communication from the CMPA s perspective This is an abridged version of presentation with cases and videos removed Dr Janet Nuth, Physician Risk Manager CMPA Associate
More informationDescribe the scientific method and illustrate how it informs the discovery and refinement of medical knowledge.
1 Describe the scientific method and illustrate how it informs the discovery and refinement of medical knowledge. Apply core biomedical and social science knowledge to understand and manage human health
More informationNovember 7, Improving Safety & Satisfaction in Ambulatory Care
1 November 7, 2013 Improving Safety & Satisfaction in Ambulatory Care 2 Having Audio Issues? If you experience any disruptions or other issues with audio during today s WIHI, we ask that you: Notify WIHIAdmin
More informationMulti disciplinary Team Communication and Effective Handoffs
Multi disciplinary Team Communication and Effective Handoffs Lauren Destino, MD Clinical Associate Professor Associate Medical Director of the Pediatric Hospital Medicine Division Stanford University,
More informationA GLOWING RESEMBLANCE A COMPARE AND CONTRAST OF MEDICAL AND NUCLEAR PERFORMANCE IMPROVEMENT INITIATIVES
A GLOWING RESEMBLANCE A COMPARE AND CONTRAST OF MEDICAL AND NUCLEAR PERFORMANCE IMPROVEMENT INITIATIVES 23 rd Annual HPRCT Conference June 12-15, 2017 Thomas Diller, MD, MMM; Executive Director University
More informationOffice of Mental Health Continuous Quality Improvement Initiative for Health Promotion and Care Coordination: 2013 Project Activities and
Office of Mental Health Continuous Quality Improvement Initiative for Health Promotion and Care Coordination: 2013 Project Activities and Expectations March 2013 Overview Welcome 2013 CQI Project Options
More informationPatient Activation Using Technology- Supported Navigators
Patient Activation Using Technology- Supported Navigators March 2, 2016 1PM Sands Expo: Lando 4205 Merrily Evdokimoff, RN, PhD Kinergy Health LLC Conflict of Interest Merrily Evdokimoff, RN. PhD Consulting
More informationImproving Sign-Outs in Hospital Medicine
Improving Sign-Outs in Hospital Medicine Arpana R. Vidyarthi, MD Assistant Professor of Medicine Division of Hospital Medicine Director of Quality, Division of Hospital Medicine Director, Patient Safety
More informationInaugural Barbara Starfield Memorial Lecture
Inaugural Barbara Starfield Memorial Lecture Wonca World Conference Prague, June 29, 2013 Copyright 2013 Johns Hopkins University,. Improving Coordination between Primary and Secondary Health Care through
More informationPatient-centered medical homes (PCMH): Eligible providers.
ACTION: Final DATE: 09/20/2016 8:11 AM 5160-1-71 Patient-centered medical homes (PCMH): Eligible providers. (A) A Patient-centered medical home (PCMH) is a team-based care delivery model led by primary
More informationAmericans Experiences with Medical Errors and Views on Patient Safety
Americans Experiences with Medical Errors and Views on Patient Safety FINAL REPORT AN IHI/NPSF RESOURCE 20 University Road, Cambridge, MA 02138 ihi.org How to Cite: NORC at the University of Chicago and
More informationThese incidents, reported by the Pennsylvania Patient Safety Authority, are
Patient safety Taking steps to protect patients from specimen-handling errors An OR specimen was transported to the laboratory. The lab called to say there was no specimen in the container. The specimen
More informationUnit Based Culture of Safety and Learning. Owensboro Health March, 2017
Unit Based Culture of Safety and Learning Owensboro Health March, 2017 Owensboro Health 477 Bed Regional Hospital 32 Bed ICU 30 Transitional Care Beds Level III Trauma Center Level III NICU Largest employer
More informationC:\Backup\rethinkeyecare
C:\Backup\rethinkeyecare Are your eyes ancillary? Vision disorders are the 4th most common disability in the United States and the most prevalent handicapping condition during childhood. The majority of
More informationPerformance Measurement of a Pharmacist-Directed Anticoagulation Management Service
Hospital Pharmacy Volume 36, Number 11, pp 1164 1169 2001 Facts and Comparisons PEER-REVIEWED ARTICLE Performance Measurement of a Pharmacist-Directed Anticoagulation Management Service Jon C. Schommer,
More informationImproving the Quality of Care Coordination Across Settings
Improving the Quality of Care Coordination Across Settings Eric A. Coleman, MD, MPH Associate Professor Divisions of Geriatric Medicine and Health Care Policy and Research University of Colorado Health
More informationUsing Data to Inform Quality Improvement
20 15 10 5 0 Using Data to Inform Quality Improvement Ethan Kuperman, MD FHM Aparna Kamath, MD MS Justin Glasgow, MD PhD Disclosures None of the presenters today have relevant personal or financial conflicts
More informationWhat Happens to the Clinical Lab Industry as:
Crises or Opportunity or Both? What Happens to the Clinical Lab Industry as:! Healthcare Transforms! Payers Get Tougher! New Diagnostic Technologies Are Used to Improve Patient Care Executive War College
More informationHealth Management Information Systems: Computerized Provider Order Entry
Health Management Information Systems: Computerized Provider Order Entry Lecture 2 Audio Transcript Slide 1 Welcome to Health Management Information Systems: Computerized Provider Order Entry. The component,
More informationDIAGNOSIS DECISION MAKING
Why and How to Improve DIAGNOSIS DECISION MAKING www.health.ebsco.com FORWARD In one of the classic papers in our field, Dr. Georges Bordage asked a very simple question: Why did I miss the diagnosis?
More informationPayer s Perspective on Clinical Pathways and Value-based Care
Payer s Perspective on Clinical Pathways and Value-based Care Faculty Stephen Perkins, MD Chief Medical Officer Commercial & Medicare Services UPMC Health Plan Pittsburgh, Pennsylvania perkinss@upmc.edu
More informationI-Pass in the NICU: Operationalizing and Sustaining Improved Handoffs
I-Pass in the NICU: Operationalizing and Sustaining Improved Handoffs Research Director Boston Children's Hospital Inpatient Pediatrics Service Director, Sleep and Patient Safety Program Brigham and Women's
More informationAPNA 28th Annual Conference Session 2038: October 23, 2014
Interprofessional Model of Geropsychiatric Care in a Program of All inclusive Care for the Elderly Pamela Z. Cacchione, PhD, APRN, BC, FAAN, Ralston House Term Chair of Gerontological Nursing, Associate
More informationREDUCING READMISSIONS through TRANSITIONS IN CARE
REDUCING READMISSIONS through TRANSITIONS IN CARE Christina R. Whitehouse, PhD, CRNP, CDE Postdoctoral Research Fellow NewCourtland Center for Transitions and Health University of Pennsylvania School of
More informationCAP Companion Society Meeting at USCAP 2009 Quality Assurance, Error Reduction, and Patient Safety in Anatomic Pathology
CAP Companion Society Meeting at USCAP 2009 Quality Assurance, Error Reduction, and Patient Safety in Anatomic Pathology Core Components of a Comprehensive Quality Assurance Program in Anatomic Pathology
More informationWhat Every Patient Safety Officer Must Know:
What Every Patient Safety Officer Must Know: Tapping into the Best Resources in the Country John R. Combes, MD Senior Medical Advisor Hospital and Healthsystem Association of Pennsylvania Harrisburg, PA
More informationPractical Application of High Reliability Principles in Healthcare to Promote Clinical Quality and Safety Outcomes
The Henderson Repository is a free resource of the Honor Society of Nursing, Sigma Theta Tau International. It is dedicated to the dissemination of nursing research, researchrelated, and evidence-based
More informationM4: Primary Care Teams: Learning from Effective Ambulatory Practices
M4: Primary Care Teams: Learning from Effective Ambulatory Practices Ed Wagner, MD, MPH, FACP, Director Emeritus, MacColl Center for Health Care Innovation Margaret Flinter, PhD, Senior Vice President
More informationPatient-Centered Case Management Assessment & Patient Interview Techniques
Patient-Centered Case Management Assessment & Patient Interview Techniques Rose M. Turner, RN, BSN, ACM Thursday, January 8 th, 2015 The information provided in AHC Media Webinars does not, and is not
More informationHigh Reliability Organizing (HRO) in the Ambulatory Setting
High Reliability Organizing (HRO) in the Ambulatory Setting High Reliability Training Sisters of Charity Leavenworth Health System 25 May 2016 2014 Healthcare Performance Improvement, LLC. ALL RIGHTS RESERVED.
More informationRyan White Part A Quality Management
Quality Management Mental Health Services Broward County/Fort Lauderdale Eligible Metropolitan Area (EMA) The creation of this public document is fully funded by a federal Ryan White CARE Act Part A grant
More informationQuality of Electronic Pathology (E-path) Records: A Function of Time, X Factors and One Constant
Quality of Electronic Pathology (E-path) Records: A Function of Time, X Factors and One Constant Jovanka Harrison, Ph.D. New York State Cancer Registry North American Association of Central Cancer Registries
More informationM2 This presenter has nothing to disclose What is High Reliability and Why Does Healthcare Need it?
M2 This presenter has nothing to disclose What is High Reliability and Why Does Healthcare Need it? Mark R. Chassin, MD, FACP, MPP, MPH President, The Joint Commission Institute for Healthcare Improvement
More informationCover Page. The handle holds various files of this Leiden University dissertation.
Cover Page The handle http://hdl.handle.net/1887/43550 holds various files of this Leiden University dissertation. Author: Brunsveld-Reinders, A.H. Title: Communication in critical care : measuring and
More informationPACE Performance on Post-Discharge Primary Care Evaluations from Jan-Jun 2012 PACE. By: Rocio Solano Padilla PCLP-NMF/GE Scholar Jul 23, 2012
PACE Performance on Post-Discharge Primary Care Evaluations from Jan-Jun 2012 PACE By: Rocio Solano Padilla PCLP-NMF/GE Scholar Jul 23, 2012 2 INTRODUCTION Who am I? Physician Assistant student Towson/CCBC
More informationPresenter Disclosure
Improving Transitions from the Hospital to Community Settings IHI National Forum Learning Lab Sunday, December 8, 2013 Presenter Disclosure MaryAnne Elma, MPH Quality Implementation and Innovations Director
More informationNexus of Patient Safety and Worker Safety
Nexus of Patient Safety and Worker Safety Jeffrey Brady, MD, MPH & James Battles, PhD Agency for Healthcare Research and Quality October 25, 2012 Diagnosing the Safety Problem is One Challenge The fundamental
More informationCare360 EHR Frequently Asked Questions
Care360 EHR Frequently Asked Questions Table of Contents Care360 EHR... 4 What is Care360 EHR?... 4 What are the current capabilities of Care 360 EHR?... 4 Is Care 360 EHR an EMR?... 5 Can I have Care360
More informationStrategies for Good Communication of the Medical Laboratory Staff with the TB Program and Healthcare Providers
Strategies for Good Communication of the Medical Laboratory Staff with the TB Program and Healthcare Providers Vasiti Uluiviti Regional Laboratory Coordinator PIHOA 2017 PITCA Meeting Sept 11 th 15 th
More informationGynecologic or Annual Women s Exam Visit & Use of Q0091 (Pap, Pelvic, & Breast Visit)
Manual: Policy Title: Reimbursement Policy Gynecologic or Annual Women s Exam Visit & Use of Q0091 (Pap, Pelvic, & Breast Visit) Section: Evaluation & Management Services Subsection: None Date of Origin:
More informationAfter The Storm Stories of Harm and Learning
Session L15 The presenters have nothing to disclose After The Storm Stories of Harm and Learning By Helen Haskell, Tanya Lord, Carolyn Canfield, Laura Townsend, and Lisa and Kirsten Morrise Dec. 6, 2015
More information3. Does the institution have a dedicated hospital-wide committee geared towards the improvement of laboratory test stewardship? a. Yes b.
Laboratory Stewardship Checklist: Governance Leadership Commitment It is extremely important that the Laboratory Stewardship Committee is sanctioned by the hospital leadership. This may be recognized by
More informationBarriers to Early Mobilization in Critically Ill Patients
Barriers to Early Mobilization in Critically Ill Patients Shannon Goddard, MD Department of Critical Care Medicine, Sunnybrook Health Sciences Centre PhD Student, Institute of Health Policy, Management
More informationImproving Transitions of Care
Improving Transitions of Care Mark V. Williams, MD, FACP, FHM Professor & Chief, Division of Hospital Medicine Northwestern University Feinberg School of Medicine Principal Investigator, Project BOOST
More informationPatient Navigation: Where did it come from and where is it going?
Patient Navigation: Where did it come from and where is it going? Lillie Shockney, RN., BS., MAS University Distinguished Service Associate Professor of Breast Cancer Administrative Director Johns Hopkins
More informationText-based Document. The Culture of Incident Reporting Among Filipino Nurses. de Guzman, Barbara Michelle. Downloaded 28-Apr :54:41
The Henderson Repository is a free resource of the Honor Society of Nursing, Sigma Theta Tau International. It is dedicated to the dissemination of nursing research, researchrelated, and evidence-based
More informationTREATMENT OF MEDICAL ERROR ISSUES AT SURGICAL M&M CONFERENCE. Prof. Alberto R. Ferreres, MD, FACS
TREATMENT OF MEDICAL ERROR ISSUES AT SURGICAL M&M CONFERENCE Prof. Alberto R. Ferreres, MD, FACS MEDICAL ERROR IN M&M CONFERENCE MEDICAL ERROR AT M&M CONFERENCE LA RESPONSABILIDAD MEDICA Y LA PRACTICA
More informationAligning Surgical Pathology & Informatics to Promote Patient Safety
Aligning Surgical Pathology & Informatics to Promote Patient Safety labinfotech infotechsummit April 11, 2008 Jeffrey L. Myers, M.D. A. James French Professor & Director, Anatomic Pathology University
More information(Muda) Objectives. Determine what is Value added vs. Non-Value added. Identify the eight types of waste. Understand the Barriers to.
Identifying Waste (Muda) Erika Sundrud, MA AVP Quality, Safety & Performance Improvement 1 Objectives Determine what is Value added vs. Non-Value added Identify the eight types of waste Understand the
More informationAgenda. NE CAH Region Discussion
NE CAH Region Discussion Tina Gagner, BSN, RN Clinical Application Analyst Agenda NDHIN Statistics Data Feeds to the HIE Participating Providers Event Notifications Communicate (Direct Secure Messaging)
More informationJune 2015 News Bulletin
June 2015 News Bulletin Claims tip of the month Patient history vs history (of) Providers may document a condition as history (of) to show that the patient has had the diagnosis for a long period of time.
More information