The Journey to High- Reliability
|
|
- Whitney Waters
- 6 years ago
- Views:
Transcription
1 The Journey to High- Reliability Georgia Osteopathic Medical Association (GOMA) 2017 Fall CME Conference 5 November 2017 Barbara Chase McKinney, MD, MPH
2 Disclosure The presentation is my own
3 Remember the Vasa
4 The Warship Vasa, Stockholm Sweden Build
5
6
7
8
9
10
11 10 August 1628
12
13 Video
14
15 By Govert Dircksz Camphuysen Inquest: Swedish Privy Council Royal Palace 5 September 1628 Captain Officers/Sailors Boat builders
16 Captain Captain Söfring Hansson Testified that the guns were secure the crew was sober
17 Officers/Sailors Was it rigged properly for the wind? Was the crew sober? Was the ballast properly stowed? Were the guns properly secured?
18 Ship Builders Henrik Hybertsson Henrik Jacobsson Arendt de Groote 'Why did you build the ship so narrow, so badly and without enough bottom that it capsized?'
19 King Gustavus Adolphus 'Imprudence and negligence = The cause Attributed to Jacob Hoefnagel ( )
20 What actually happened?
21 Objectives for today Determine Best Practices to Build a Culture of Safety Define Quality Improvement (QI) and the goal of QI efforts State the three elements that together lead to High Reliability Be Inspired to create High Reliability in your practice Implement one practice of high reliability by Next Tuesday
22 The great aim of education is not knowledge, but action! Herbert Spencer
23 GOMA Fall CME Conference NOVEMBER 2011
24
25 High Reliability Why? What/How? When?
26 WHY?
27 The Quality & Safety Movement The US Timeline Benign Ignorance IOM Report: Crossing the Quality Chasm Affordable Care Act Pay for Performance IOM Report: To Err is Human IHI 100,000 Lives Campaign
28 The Institute of Medicine Report: To Err is Human September ,ooo 98,ooo lives lost / year due to medical errors $17-$29 billion financial cost Loss of Trust Medical errors can be defined as the failure of a planned action to be completed as intended or the use of a wrong plan to achieve an aim.
29 The Quality & Safety Movement The US Timeline Benign Ignorance IOM Report: Crossing the Quality Chasm Affordable Care Act Pay for Performance IOM Report: To Err is Human IHI 100,000 Lives Campaign
30 High Profile Cases 2001 Josie King s Story & others Prompted Patient Safety Efforts
31 Where are we now? Consumer Reports - May 2013
32 Study Suggests Medical Errors Now Third Leading Cause of Death in the U.S. BMJ 2016;353:i2139 doi: /bmj.i2139 (Published 3 May 2016)
33 Killer Care: How Medical Error Became America s Third Largest Cause of Death and What Can Be Done About It, By James B Lieber, OR Books 2015
34
35 WHAT? HOW? What can be done? How to start?
36 Five Suggested Reforms 1. Adopt Structured Handoffs 2. Bring in the Pharmacists 3. Get Serious about Infection 4. Fight Diagnostic Error 5. Make Electronic Health Records Interoperable Killer Care: How Medical Error Became America s Third Largest Cause of Death and What Can Be Done About It, By James B Lieber, OR Books 2015
37 IOM s Six Aims for Healthcare Improvement Healthcare must be: SAFE EFFECTIVE PATIENT-CENTERED TIMELY EFFICIENT EQUITABLE The Joint Commission s (TJC) Performance Metrics are built around these six aims
38 Quality VALUE The Value Equation Value = Quality (Outcomes + Safety + Service) Cost
39
40 GOMA Fall CME Conference NOVEMBER 2011
41 Quality Improvement is Combined and unceasing efforts of everyone healthcare professionals, patients and their families, researchers, payers, planners and educators to make changes that will lead to better patient outcomes (health), better system performance (care) and better professional development (learning) The Goal = Transformation of Healthcare Batalden, P and Davidoff, F; What is quality improvement and how can it transform healthcare? Qual Saf Health Care 2007;16:1 2-3 doi: /qshc Downloaded from on September 1, 2015
42 Learning Board Examples
43
44 The Role of a Fair and Just Culture
45 What will you do by next Tuesday? Communicate - Behavior Huddle Brief Debrief Handoff Team Move a Metric Learning System Surface Issues Create an Aim Statement Select a Metric PDSA
46
47 Process Improvement + Culture of Safety + Leadership = High Reliability
48
49 Process Improvement Culture of Safety Leadership How to Build High Reliability Quality /Process Improvement Evidence Based Medicine Standardize Work as a Team Safety Huddles Speak Up Time Outs Read Back Listen Actively engage front-line staff, patients & family Joy in your work
50 WHEN? What can you do by next Tuesday?
51 Remember the Vasa
52 Questions? Comments? Feedback? Thank You
Quality Improvement in Health and Social Care
Some Fundamentals on Quality Improvement in Health and Social Care Towards a Shared Understanding EPSO, Reykjavik, 2017-09-26 Johan Thor, MD, MPH, PhD Associate Professor E-mail: johan.thor@ju.se The death
More informationM16 Is there a perfect system?
M16 Is there a perfect system? Scotland s Quality Journey 1 NHSScotland 5 million people 12 billion 14 Health Boards 8 Support Boards Integrated delivery Moving towards social care integration Public Finances
More informationQuality Improvement: Let s build a better system together! 2018 OCAN THINK TANK M I C H A E L D U N N
Quality Improvement: Let s build a better system together! 2018 OCAN THINK TANK M I C H A E L D U N N The Excellence through Quality Improvement Project (E-QIP) E-QIP is a partnership initiative between
More informationPatient- and Family-Centered Care
Patient- and Family-Centered Care This Orientation Offers a brief overview of: Core concepts of patient- and family-centered care; Measures/outcomes impacted by patient- and family-centered care; Ways
More informationIMPROVING QUALITY AND SAFETY WHERE PATIENTS, FAMILIES, AND CARE TEAMS MEET THE CLINICAL MICROSYSTEM
IMPROVING QUALITY AND SAFETY WHERE PATIENTS, FAMILIES, AND CARE TEAMS MEET THE CLINICAL MICROSYSTEM Gautham Suresh, MD, MS Associate Professor of Pediatrics and Community & Family Medicine Medical Director,
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 informationA3/B3: Improvement in the Intensive Care Unit
A3/B3: Improvement in the Intensive Care Unit Carol Peden, MD, MPH, FRCA, FFICM, Associate Medical Director for Quality Improvement, Consultant in Anesthesia and Intensive Care Session Objectives Structure
More informationTHE AMERICAN BOARD OF PATHOLOGY PATIENT SAFETY COURSE APPLICATION
THE AMERICAN BOARD OF PATHOLOGY PATIENT SAFETY COURSE APPLICATION Requirements: Component I Patient Safety Self-Assessment Program Programs must meet the following criteria to be an ABP approved Patient
More informationImproving Clinical Flow ECHO Collaborative Change Package
Primary Drivers (driver diagram) Change Concepts Change Ideas Examples, Tips, and Resources Engaged Leadership Develop culture for transformation Use walk-arounds and attendance at team meetings to talk
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 informationQuality Management of Healthcare
Management of Healthcare Shell Conference This Session Introduction Urgency Improvement Management 1 Hello! Industrial and Systems Engineer MS in Health Systems Engineering Past Work: Hospital Based Improvement
More informationHow do you spell better teamwork and communication? TeamSTEPPS! November 30, 2017
How do you spell better teamwork and communication? TeamSTEPPS! November 30, 2017 Objectives of the call: Learn more about the experience of each organization on their TeamSTEPPS journey. Discover how
More informationIntroduction. Singapore. Singapore and its Quality and Patient Safety Position 11/9/2012. National Healthcare Group, SIN
Introduction Singapore and its Quality and Patient Safety Position Singapore 1 Singapore 2004: Top 5 Key Risk Factors High Body Mass (11.1%; 45,000) Physical Inactivity (3.8%; 15,000) Cigarette Smoking
More informationTeamSTEPPS Introductory Webinar. July 19, 2018
TeamSTEPPS Introductory July 19, 2018 Agenda Welcome & HIIN Update TeamSTEPPS Master Trainer Course Presentation --Duke University Health System Master Trainers Next Steps Questions / Discussion Pre-Meeting
More information100 Million Healthier Lives
100 Million Healthier Lives Ninon Lewis, MS Executive Director, Triple Aim for Populations Focus Area Institute for Healthcare Improvement Soma Stout, MD MS Executive External Lead, Health Improvement,
More informationQuality Improvement: Is it for payers or patients? Michael D. Kappelman Canadian Digestive Diseases Week February 9, 2014
Quality Improvement: Is it for payers or patients? Michael D. Kappelman Canadian Digestive Diseases Week February 9, 2014 Accreditation This event has been approved as an accredited (Section1) group learning
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 informationMedical Education Across the Continuum: A Snapshot in Time
2014 MMS Annual Oration Medical Education Across the Continuum: A Snapshot in Time 2004-2014 Michele P Pugnaire MD Senior Associate Dean for Educational Affairs UMass Medical School Massachusetts Medical
More informationUsing your EHR to Facilitate Effective Patient Population Management Real World Strategies. Jen Brull, MD Family Physician Plainville, KS
Using your EHR to Facilitate Effective Patient Population Management Real World Strategies Jen Brull, MD Family Physician Plainville, KS Objectives Utilize both population health and patient-specific tools
More informationPursuing Perfect Depression Care: A Model for Eliminating Suicide and Transforming Mental Healthcare
A Model for Eliminating Suicide and Transforming Mental Healthcare C. Edward Coffey, M.D. Henry Ford Health System Detroit, MI Outline of Presentation Case Presentation A Health Care System in Shambles
More informationPromoting Transparency, Teamwork, and Real-time Review: The Morning Safety Huddle. St. Christopher s Hospital for Children
Promoting Transparency, Teamwork, and Real-time Review: The Morning Safety Huddle St. Christopher s Hospital for Children 1 Agenda Facility Overview Evolution of the Morning Safety Huddle Structure of
More informationUsing Transparency to Drive Patient Safety
Session Code These presenter s have nothing to disclose Using Transparency to Drive Patient Safety Doug Salvador, MD MPH Chief Quality Officer, Baystate Health Chief Medical Officer, Baystate Medical Center
More information1875 Connecticut Ave. NW / Suite 650 / Washington, D.C / / fax /
Testimony of Jane Loewenson Director of Health Policy, National Partnership for Women & Families Before the U.S. House of Representatives Energy & Commerce Subcommittee on Health Hearing on Patient Safety
More informationTo Err is Human To Delay is Deadly Ten years later, a million lives lost, billions of dollars wasted
1999 Institute of Medicine study estimated that as many as 98,000 people die in any given year from medical errors that occur in hospitals. To Err is Human To Delay is Deadly Ten years later, a million
More informationQuality Improvement. Goals & Objectives. u What is Quality Health Care. u Where are the gaps in care JOHN W. RAGSDALE, III, MD JULY 2017
Quality Improvement JOHN W. RAGSDALE, III, MD JULY 2017 DEPARTMENT OF COMMUNITY AND FAMILY MEDICINE PRIMARY CARE SEMINAR SEA PINES, SC Goals & Objectives u What is Quality Health Care u Where are the gaps
More informationNursing Home Quality Care Collaborative Team Communication. 20 April 2017
Nursing Home Quality Care Collaborative Team 20 April 2017 Interacting with the Webinar 2 Slides & Recording Registrants were sent a PDF of the slides in advance of the webinar The slides and a recording
More informationQuality and Safety. David V. Condoluci, DO., M.A.C.O.I.
Quality and Safety David V. Condoluci, DO., M.A.C.O.I. Objectives: Quality and Safety What does it mean? 1. What is quality and safety in medical care 2. What is a High Reliable Organization 3. Help me
More informationImprovement Science and Quality; Scotland s Journey. Prof Jason Leitch Clinical Director The Quality Unit, Scottish Government
Improvement Science and Quality; Scotland s Journey Prof Jason Leitch Clinical Director The Quality Unit, Scottish Government Improvement Science Jason Leitch Clinical Director The Quality Unit, Scottish
More informationHow can I make safety huddles work in my area?
How can I make safety huddles work in my area? Safety Huddles: How can I make patient safety huddles work for my area? Dr Ali Cracknell Consultant in Medicine for Older People (Leeds Teaching Hospitals
More informationDelivering Great Care with High Reliability
FE4 These presenters have nothing to disclose Delivering Great Care with High Reliability The Orlando Health Journey December 5, 2016 Joelle Baehrend, MA Director, Institute of Healthcare Improvement 1
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 informationDEFINING HIGH VALUE CONTINUING PROFESSIONAL DEVELOPMENT
DEFINING HIGH VALUE CONTINUING PROFESSIONAL DEVELOPMENT Ronald M. Cervero, PhD Uniformed Services University of the Health Sciences Exploring a Business Case for High-Value CPD A Workshop of the Global
More informationDelivering Great Care with High Reliability The Orlando Health Journey
FE5 These presenters have nothing to disclose Delivering Great Care with High Reliability The Orlando Health Journey December 11, 2017 Frank Federico, RPh Vice President Patricia McGaffigan, RN, MS, CPPS
More informationCRITICAL ANALYSIS OF INTERNATIONAL PATIENT SAFETY GOLAS STANDARDS IN JCI ACCREDITATION AND CBAHI STANDARDS FOR HOSPITALS
IMPACT: International Journal of Research in Business Management (IMPACT: IJRBM) ISSN (E): 2321-886X; ISSN (P): 2347-4572 Vol. 4, Issue 3, Mar 2016, 71-78 Impact Journals CRITICAL ANALYSIS OF INTERNATIONAL
More informationImproving Patient Experience in Outpatient Services
Improving Patient Experience in Outpatient Services Jenny King Chief Research Officer @scoopyoiseau www.picker.org Picker Our vision: the highest quality health and social care for all, always. We are
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 informationDesign Principles for Learning and Caring in Patient-Centered Primary Care Homes
The H.R. Bob Brettell, MD, Memorial Lectureship January 29, 2013 Design Principles for Learning and Caring in Patient-Centered Primary Care Homes Judith L. Bowen, MD, FACP Professor of Medicine Oregon
More informationWhat is High Reliability and Why Does Healthcare Need it?
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 25th Annual Forum Orlando, FL December
More informationTo err is human. When things go wrong: apology and communication. Apology and communication position statement
When things go wrong: apology and communication Kristi Eldredge R.N., J.D., CPHRM Senior Risk and Safety Consultant Fresident To err is human position statement To err is human. Mistakes are part of the
More informationIntegrating quality improvement into pre-registration education
Integrating quality improvement into pre-registration education Jones A et al (2013) Integrating quality improvement into pre-registration education. Nursing Standard. 27, 29, 44-48. Date of submission:
More informationSafety Huddles: Bringing fun to the frontline and reducing harm
Safety Huddles: Bringing fun to the frontline and reducing harm Alison Lovatt Clinical Network Director, Improvement Academy Ali Cracknell Consultant Medicine For Older People, Leeds Teaching Hospitals
More informationSWAN Alerts and Best Practices for Improved Care Coordination
SWAN Alerts and Best Practices for Improved Care Coordination IHIN and SWAN Course Overview Our Goal: To educate healthcare providers in how to manage SWAN alerts for meaningful impact at the point of
More information9/9/2016. How Respiratory Therapist Enhance Patient Safety. Introduction. Raise your hand. Tawana Shaffer CPHRM, MBA, BSc, CRT
How Respiratory Therapist Enhance Patient Safety Tawana Shaffer CPHRM, MBA, BSc, CRT Introduction Raise your hand 1 How do you define Patient Safety? What is Patient Safety? Communication Care Falls Outcomes
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 informationJoy in Medicine Physician well-being: A discussion on burnout and achieving joy in practice
Joy in Medicine Physician well-being: A discussion on burnout and achieving joy in practice AMA s SL2 (Share, Listen, Speak, Learn) Series December 2017 Share, Listen, Speak, Learn (SL2) Series Share existing
More informationIHI Expedition. Engaging Frontline Teams to Create a Culture of Safety. March 28 th, Annette Bartley, RN, MS, MPH Tracy Jacobs, BSN, RN
March 28 th, 2013 These presenters have nothing to disclose IHI Expedition Engaging Frontline Teams to Create a Culture of Safety Annette Bartley, RN, MS, MPH Tracy Jacobs, BSN, RN Today s Host 2 Lizzie
More informationCertificate Program in Practice-Based Research Methods
Certificate Program in Practice-Based Research Methods UTILIZING QUALITY IMPROVEMENT FOR PBRN RESEARCH Session 7 - January 12, 2017 Chester H. Fox MD, FAAFP, FNKF Professor of Family Medicine Jacobs School
More informationCreating and Sustaining A Family Advisory Council (FAC) Hayley Hirschmann, Alexa O Dell. Creating and Sustaining A Family Advisory Council (FAC)
Next 2 Creating and Sustaining A Family Advisory Council (FAC) Co-Presenters: Hayley Hirschmann, FAC Coordinator/Parent Saint Barnabas Medical Center, Livingston, NJ Alexa O Dell, FAC Chair Benefis NICU,
More informationCampaign for Meds Management (CMM) April 26, 2016
Campaign for Meds Management (CMM) April 26, 2016 Housekeeping You will need to access your registration confirmation email and registration ID to login to WebEx Thank you for joining us in the WebEx Event
More informationAn Implementation Framework for Patient Safety in Ambulatory Care. To disseminate key findings from IHI s work on ambulatory safety
An Implementation Framework for Patient Safety in Ambulatory Care Jennifer Lenoci-Edwards, RN, MPH, CPPS Director of Patient Safety, IHI Richard Braunstein, MD Executive Director, Manhattan Eye, Ear &
More informationDeveloping the Leaders of Tomorrow. Joan M. Simon, MSA, BSN, RN, CENP, NEA-BC, FACHE
Developing the Leaders of Tomorrow Joan M. Simon, MSA, BSN, RN, CENP, NEA-BC, FACHE Agenda WHAT IS ALL THE FUSS ABOUT? LEADERSHIP SKILLS FOR 2020 AND BEYOND BUILDING & SUSTAINING HEALTHY WORK ENVIRONMENTS
More informationA26/B26: Goal Zero: South Carolina s Commitment to Safety
A26/B26: Goal Zero: South Carolina s Commitment to Safety Coleen Smith, RN, MBA, CPHQ, High Reliability Initiatives Director Joint Commission Center for Transforming Healthcare Thornton Kirby, FACHE, President
More informationHEALTHCARE INFORMATION SYSTEMS: ENABLERS FOR QUALITY IMPROVEMENT. Kenneth W. Kizer, M.D., M.P.H. President and CEO National Quality Forum
HEALTHCARE INFORMATION SYSTEMS: ENABLERS FOR QUALITY IMPROVEMENT Kenneth W. Kizer, M.D., M.P.H. President and CEO National Quality Forum January 14, 2002 The Paradox of American Healthcare 2003 Highly
More informationTransforming Delivery Systems for Population Health
Transforming Delivery Systems for Population Health George Isham, M.D., M.S. Senior Advisor, HealthPartners Senior Fellow, HealthPartners Institute for Education and Research October 9, 2015 Presenter
More information2/15/2016. To Err is Human. Patient Safety in OB/GYN: Current Trends. At the conclusion of this talk. Published by IOM in 1999
Patient Safety in OB/GYN: Current Trends Joseph R. Biggio Jr., MD Objectives At the conclusion of this talk Comprehend the underlying rationale for the increasing emphasis on patient safety Understand
More informationZERO It s powerful. It s controversial. And it s the cornerstone of high reliability organizations.
ZERO It s powerful. It s controversial. And it s the cornerstone of high reliability organizations. 1 Thornton Kirby, President & CEO South Carolina Hospital Association Lorri Gibbons, RN, MSHL Vice President
More informationWhat is Quality Improvement?
What is Quality Improvement? Alan D Rogers, MBChB, MMed, FC Plast Surg (SA), FRCSI, MSc Plastic and Reconstructive Surgeon, Ross Tilley Burn Centre, Sunnybrook Health Sciences Centre, Toronto; and Assistant
More informationHealth Management Information Systems
Health Management Information Systems Computerized Provider Order Entry (CPOE) Computerized Provider Order Entry (CPOE) Learning Objectives 1. Describe the purpose, attributes and functions of CPOE 2.
More informationAn RHC Patient Centered Medical Home Experience
An RHC Patient Centered Medical Home Experience NARHC October 19, 2017 Kate Hill, RN The Compliance Team MACRA Recognition TCT Recognized for it s PCMH Program Today s Objectives Understand the difference
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 informationVASCULAR HEALTH QI TOOLKIT
VASCULAR HEALTH QI TOOLKIT DECEMBER 2016 VASCULAR HEALTH QI TOOLKIT TABLE OF CONTENTS 1. Determining Readiness for Change... 3 a) Assessing for team/practice capacity b) Assessing for measurement capacity
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 informationDefining an Outcome Measures Framework for Global Surgery
Defining an Outcome Measures Framework for Global Surgery Richard Gliklich MD Leffenfeld Professor of Otology and Laryngology, Harvard Medical School Surgeon, Mass Eye and Ear; Massachusetts General Hospital
More informationNDNQI Rhythms in Quality 2010 Data Use Conference
NDNQI Rhythms in Quality 2010 Data Use Conference National Priority Partners Goals and Opportunities for Nurses Care Coordination Spotlight Gerri Lamb, PhD, RN, FAAN Arizona State University January 21-22,
More informationCommunity Care Coordination Cross Continuum Care IHC Medical Home Conference September 5, 2012 Des Moines IA
Community Care Coordination Cross Continuum Care IHC Medical Home Conference September 5, 2012 Des Moines IA Peg Bradke, RN, MA Director of Heart Care Services St. Luke s Hospital, Cedar Rapids, IA Session
More informationNursing Curriculum Trends. Claire Byrne, MSN RN NE-BC
Nursing Curriculum Trends Claire Byrne, MSN RN NE-BC Disclosure I, Claire Byrne MSN RN NE-BC, do not have a financial interest / arrangement or affiliation with any organization that could be perceived
More informationFostering a Culture of Safety
Fostering a Culture of Safety June 11, 2017 Alabama Society of Health System Pharmacists Presenter: Trey Gwin, RPh, MBA, Medication Safety Coordinator, Infirmary Health Financial Disclosure The speaker
More informationOrganization: Sinai Hospital of Baltimore
Organization: Sinai Hospital of Baltimore Solution Title: Increased Awareness of Patient Safety and Quality Improvement Principles with the Implementation of a Hospital-Wide Patient Safety and Quality
More informationHow U.S. Health Care Got Safer by Focusing on the Patient Experience ARTICLE PERFORMANCE MEASUREMENT. by Thomas H. Lee, MD
REPRINT H03O8L PUBLISHED ON HBR.ORG MAY 31, 2017 ARTICLE PERFORMANCE MEASUREMENT How U.S. Health Care Got Safer by Focusing on the Patient Experience by Thomas H. Lee, MD This article is made available
More informationIntroduction to QI and HIT. Objectives. Health Care. Unit 1a: Health Care Quality and HIT
Introduction to QI and HIT Unit 1a: Health Care Quality and HIT This material was developed by Johns Hopkins University, funded by the Department of Health and Human Services, Office of the National Coordinator
More informationLEADERSHIP CHALLENGES IN PATIENT SAFETY
LEADERSHIP CHALLENGES IN PATIENT SAFETY Kenneth W. Kizer, MD, MPH. California Hospital Patient Safety Organization Annual Meeting Sacramento, CA April 8, 2013 Presentation Charge Discuss some of the challenges
More informationA Better. an America 2050 project
A Better Tomorrow an America 2050 project A Better Tomorrow an America 2050 project Overview America 2050 and Spencer Trask Collaborative Innovations are launching a web-based, collaborative innovation
More informationLeadership and Culture: Building Highly Reliable Systems of Care
Learning Objectives Leadership and Culture: Building Highly Reliable Systems of Care Michael Batchelor, CEO Baptist Easley Hospital Easley, South Carolina Discuss recent developments in health systems
More informationSetting: Emergency departments are high-risk contexts; they are over-crowded and
QUALITY IMPROVEMENT STUDENT PROJECT PROPOSAL: IMPROVING HANDOFFS IN SAN FRANCISCO GENERAL HOSPTITAL S EMERGENCY DEPARTMENT TMIT Student Projects QuickStart Package 1. BACKGROUND Setting: Emergency departments
More informationA Comprehensive Framework for Patient Safety
These presenters have nothing to disclose A Comprehensive Framework for Patient Safety Allan Frankel, MD and Carol Haraden, PhD 8 October 2015 A Framework for a System of Safety Objectives 1. Link safety
More informationAn Implementation Framework for Patient Safety in Ambulatory Care
An Implementation Framework for Patient Safety in Ambulatory Care Jennifer Lenoci-Edwards, RN, MPH, CPPS Director of Patient Safety, IHI Richard Braunstein, MD Executive Director, Manhattan Eye, Ear &
More informationStrategy Guide Specialty Care Practice Assessment
Practice Transformation Network Strategy Guide Specialty Care Practice Assessment 1/20/2017 1 Strategy Guide: Specialty Care PAT 2.2 Contents: Demographics Tab: 3 Question 1: Aims... 3 Question 2: Aims...
More informationPCMH Success Plan. Quick Review. Why Are We Here? What Have We Done? Where Are We Going? 5/18/2015. May 15, 2015
PCMH Success Plan May 15, 2015 Angie Charlet, ICAHN Facilitator Joann Emge, Co-Chair Ken Reid, Co-Chair Quick Review Why Are We Here? What Have We Done? Where Are We Going? 1 The Shaky Bridge Build Common
More informationWriting Manuscripts About Quality Improvement: SQUIRE 2.0 and Beyond
Writing Manuscripts About Quality Improvement: SQUIRE 2.0 and Beyond Author Marilyn H. Oermann, PhD, RN, ANEF, FAAN Thelma M. Ingles Professor of Nursing, Duke University School of Nursing Editor, Journal
More informationHealth Care Systems - A National Perspective Erica Preston-Roedder, MSPH PhD
Health Care Systems - A National Perspective Erica Preston-Roedder, MSPH PhD Outline Quality Overview Overview and discussion of CMS programs Increasing transparency Move from P4R to P4P Expanding beyond
More informationQuality Improvement Developing Psychology s QI Capability
Quality Improvement Developing Psychology s QI Capability APPIC May 2016 Liza Bonin, Ph.D. labonin@texaschildrens.org Disclosure UpToDate clinical decision support resource Wolters Kluwer Health UpToDate
More informationRapid Response Team and Patient Safety Terrence Shenfield BS, RRT-RPFT-NPS Education Coordinator A & T respiratory Lectures LLC
Rapid Response Team and Patient Safety Terrence Shenfield BS, RRT-RPFT-NPS Education Coordinator A & T respiratory Lectures LLC Objectives History of the RRT/ERT teams National Statistics Criteria of activating
More informationKeeping Your Diabetes Education Program Stable In the Era Of Health Care Reform and Accountable Care Organizations
Keeping Your Diabetes Education Program Stable In the Era Of Health Care Reform and Accountable Care Organizations Nicole Downey, MBA, RD, CDE Program Director Diabetes Services The Polyclinic Seattle,
More informationBuilding a Safe Healthcare System
Building a Safe Healthcare System Objectives 2 Discuss the process of improving healthcare systems. Introduce widely-used methodologies in QI/PS. What is Quality Improvement? 3 Process of continually evaluating
More informationAF4Q and TCAB: An Introduction
AF4Q and TCAB: An Introduction July 13, 2011 Ellen Interlandi, MHM, RN, NE-BC Patricia Montoya, MPA, BSN 1 What is Aligning Forces for Quality? An unprecedented commitment by the Robert Wood Johnson Foundation
More informationSafe Care Across the Health Care Continuum Primary Care
This presenter has nothing to disclose. Safe Care Across the Health Care Continuum Primary Care Jennifer Lenoci-Edwards, RN, MPH March 6, 2017 Activity Time What would it take? Objectives Discuss the state
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 informationTRANSFORMING HEALTHCARE: Educating the Healthcare Workforce For Quality and Safety Practice and Innovation
TRANSFORMING HEALTHCARE: Educating the Healthcare Workforce For Quality and Safety Practice and Innovation Donna Woods, EdM, PhD Assistant Professor and Co Director, Graduate Programs In Healthcare 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 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 informationIncident Reporting Systems and Future Strategies for Patient Safety Improvement
WHITE PAPER: Incident Reporting Systems and Future Strategies for Patient Safety Improvement Author: Datix Date: 2016/17 Driving down harm How can healthcare providers most successfully pursue the goal
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 informationIPE and Simulation. Advancing Nursing Education and Practice. Martha A. Conrad, RN, MSN Director of Interprofessional Simulation
IPE and Simulation Advancing Nursing Education and Practice Martha A. Conrad, RN, MSN Director of Interprofessional Simulation mconrad@uakron.edu November 1, 2014 Objectives Define Interprofessional Education
More informationUpdate on ACG Guidelines Stephen B. Hanauer, MD President American College of Gastroenterology
Update on ACG Guidelines Stephen B. Hanauer, MD President American College of Gastroenterology Clifford Joseph Barborka Professor of Medicine Northwestern University Feinberg School of Medicine Guideline
More informationPOPULATION HEALTH MANAGEMENT, PROGRAMS, MODELS, AND TOOLS A. LEE MARTINEZ DBH-C, MA, LAC, CPHQ
POPULATION HEALTH MANAGEMENT, PROGRAMS, MODELS, AND TOOLS A. LEE MARTINEZ DBH-C, MA, LAC, CPHQ Learning objectives At the conclusion of this session, the participant will be able to: Learning Objective
More informationCurricular Thread Report: Patient Saftety/Quality Improvement
Curricular Thread Report: Patient Saftety/Quality Improvement Contributors: Jerald Mullersman, MD, PhD; John Franko, MD; Salah Shurbaji, MD; Rachel Walden, MLIS; Nakia Woodward, MS; Faris Bakeer, MS4 Key
More informationFrontline Improvement Using Defect Analysis March 9, 2012 R Resar, MD; N Romanoff, MD, MPH; A Majka, MD; J Kautz, MD; D Kashiwagi, MD; K Luther, RN
Frontline Improvement Using Defect Analysis March 9, 2012 R Resar, MD; N Romanoff, MD, MPH; A Majka, MD; J Kautz, MD; D Kashiwagi, MD; K Luther, RN Introduction More than a decade ago, the Institute of
More informationThe Vision for the Future
Project Destiny Executive Summary The American Pharmacists Association (APhA), the National Association of Chain Drug Stores (NACDS), and the National Community Pharmacists Association (NCPA) have joined
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 informationThe Journey towards zero avoidable pressure ulcers
The Journey towards zero avoidable pressure ulcers Annette Bartley RGN MSc MPH Quality Improvement Consultant Health Foundation/Institute for Healthcare Improvement Quality Improvement Fellow Understanding
More information