Reigniting Our Passion for Safe Care

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1 Minnesota Alliane for Patient Safety (MAPS) Conferene Reigniting Our Passion for Safe Care Ot , 2018 Minneapolis Marriott Northwest, Brooklyn Park

7:30 8:30 a.m. Registration Thursday, Ot. 25 8:30 8:40 a.m. Welome and Opening Remarks 8:40 9:40 a.m. Opening Session: Just Culture Then and Now Sponsored by the Minnesota Hospital Assoiation 9:40 10 a.

2 7:30 8:30 a.m. Registration Thursday, Ot. 25 8:30 8:40 a.m. Welome and Opening Remarks 8:40 9:40 a.m. Opening Session: Just Culture Then and Now Sponsored by the Minnesota Hospital Assoiation 9:40 10 a.m. Break David Marx, hief exeutive offier, Outome Engenuity, Minneapolis, MN Safety in the workplae is important, but how do we establish a ulture that enourages open reporting of adverse events and risky situations, yet holds people and organizations aountable in a just manner? The hallenge lies in distinguishing between a system that might reate risks, human error whih may result in a bad outome and rekless behavior that intentionally puts lives or organizations at risk. In our opening session, Marx will explain how Just Culture reshapes our understanding of aountability, the role of the system and the role of human behavior, allowing us to distinguish between human behaviors to help us arrive at a onsistent way to establish a safe environment by managing the system and behavior a.m. Breakout Sessions 11:15 a.m. 12:15 p.m. Breakout Sessions #1 Understanding and Responding to Dementia-Related Behaviors: A Guide for All Staff Roles Katie Roberg, program and eduation manager, Alzheimer s Assoiation Minnesota-North Dakota Chapter, Edina, MN Some of the greatest hallenges in providing are for an individual with dementia are the personality and behavior hanges that often our. This session will provide valuable strategies for staff in all areas of your organization to identify and respond to hallenging behaviors assoiated with dementia in order to provide safe, person-entered are and enhane the lives of individuals living with dementia. #2 Open Notes Roxana Lupu, M.D., Sanford Health, Sioux Falls, SD Open Notes is an international movement that promotes transpareny and enourages health are providers to share visit doumentation. Providing aess to notes an empower patients, families and aregivers to feel more in ontrol of health are deisions, help manage are and improve the overall quality and safety of are. This session will present the implementation proess inluding barriers and hallenges, physiian and patient feedbak, as well as further plans for expansion. #3 Weaving Together the Critial Components of a Strong and Comprehensive Patient Safety Program Sponsored by the MMIC Group Panelists: Chelsie Bakken, MBA, BSN, RN, oordinator, patient safety and Melissa Jones, MHA, BSN, RN, CNOR, CPSO, senior proess improvement linial onsultant, CentraCare Health-St. Cloud Hospital, St. Cloud, MN; Failitator: Martin J. Hatlie, J.D., o- diretor, Center for Open and Honest Communiation, MedStar Institute for Quality and Safety (MIQS) Washington, DC This session will explore the impat of harm events on the resiliene of the are team and the effets on safety and experiene. Panelists will emphasize the importane of providing immediate and ongoing emotional support to staff, patients and loved ones following unexpeted events and weave together the strands of patient experiene, patient safety and resiliene, disussing how the three work together to support and strengthen eah other. They will explain how the key aspets of CANDOR provide an interwoven foundation for an organization to establish a learning ulture and trusting relationship with patients, families and their are teams. #4 Human Centered Design for Performane Improvement Laurie Bell, are transformation program manager, Jill Goring, diretor of nursing pratie, eduation and researh, Pam Peine, nurse manager, MICU, and Jason Robertson, M.D., SFHM, hief of internal mediine, Regions Hospital, St. Paul, MN Are your fixes to re-emerging problems starting to feel like Band-Aids for a major bleed? Do you spend too muh time rolling out improvements that do not get adopted? If so, you may want to onsider using Human- Centered Design (HCD). HCD is understanding the lived experienes of the people with whom you interat so that your designed produt or servie will be meaningful and of value. The Regions team will disuss their HCD experienes that led to a sustained redution in hospital aquired onditions and infetions, improvements in nurse onboarding and eduation and hospitalist driven design that supports top of liense work for all are team members.

12:15 1:15 p.m. Lunh #5 Rae, Raism and Health Inequity: What Can We Do About It? Stephen Nelson, M.D. diretor of sikle ell linis, Children s of Minnesota, Minneapolis, MN This presentation is born out of work done by Dr.

3 12:15 1:15 p.m. Lunh #5 Rae, Raism and Health Inequity: What Can We Do About It? Stephen Nelson, M.D. diretor of sikle ell linis, Children s of Minnesota, Minneapolis, MN This presentation is born out of work done by Dr. Nelson and the reognition of the impat of raism and provider bias on raial disparities in health are. Nelson has done extensive researh and training on this ontent extensively for the last 7 years and, with Dr. Heather Hikman, has been onduting raial justie trainings for physiians, nurses, students and others in the Upper Midwest. As a result, he has arued information regarding the transformation of raial disparities and will share this in his presentation. #6 Community-Based Care Collaboration Prevents Opioid Abuse Kurt Devine, M.D., and Heather Bell, M.D., CHI St. Gabriel s Health, Little Falls, MN In response to the opioid epidemi, CHI St. Gabriel s Health helped develop an innovative model to prevent presription drug and opioid abuse. As part of a $45 million State Innovation Model (SIM) ooperative agreement to help implement the Minnesota Aountable Health Model, the hospital launhed the program in partnership with the ounty sheriff s offie, loal polie department, ounty soial servie and publi health agenies, loal shool distrit, loal pharmaies and home health servies, along with skilled nursing failities. As a result, presription drug usage has dereased substantially. Join us as we hear from this award-winning team about their ollaboration with multiple partners, lessons-learned and suesses. Sponsored by Fairview Health Servies 1:15 2:15 p.m. General Session: Patient Story Sponsored by LeadingAge Minnesota Patient panelists: Arabella Jones and Dar Hafner; Failitator: Lisa Juliar, engagement speialist, Minnesota Alliane for Patient Safety, Minneapolis, MN In an effort to understand the toll that human error an take on the lives of those reeiving and delivering are, you will hear heart-felt stories from onsumers who have experiened an error in their are journey. This session will provide lessons you an take bak to your organization to enourage a safer, stronger and more trusting environment. Join us as we disover the ways to reignite our passion and build our knowledge to eliminate harm from our systems of are delivery. 2:15 2:30 p.m. Break 2:30 3:30 p.m. General Session: Patient Safety and the Human Condition Sponsored by Allina Health Danielle Ofri, M.D., Ph.D., author, linial professor of mediine, New York University Shool of Mediine, New York, NY Patient safety is a ritial issue in mediine today. There is, rightly, a strong emphasis in systems approahes to improving medial are and dereasing error. However, mediine is fundamentally a human endeavor, and in the end, it is people, not systems, who ause medial errors. Without attention to the human aspets of the medial enterprise emotions, respet, relationships ruial aspets of patient safety will remain beyond our grasp. Friday, Ot. 26 8:30 9:30 a.m. General Session: Shared Deision Making Sponsored by Mayo Clini Vitor Montori, M.D., M.S., speaker, author, professor of mediine, Mayo Clini, Rohester, MN What is shared deision making? The Ageny for Healthare Researh and Quality (AHRQ) desribes it as a mode of patient-entered are that enables and enourages people to play a role in the medial deisions that affet their health. Montori believes that we need to see people in high definition with flexibility and empathy. Join us as we look at the future of the next health system and aim towards being effiient and sustainable with the priority on its mission and holding itself aountable to patients and their are. 9:45 10:45 a.m. Breakout Sessions #7 Human Fators Engineering: What is it and How Do We Use it? Sponsored by the Minnesota Medial Assoiation Matthew Sanlon, M.D., CPPS, professor of pediatris, Medial College of Wisonsin, physiian, Children s Hospital of Wisonsin, Milwaukee, WI Human Fators Engineering is an inredibly important but often misunderstood siene. This session will explain the basis while identifying strategies to use Human Fators Engineering to improve the safety of are.

10:45 11 a.m. Break #8 Partnerships Make Safety Possible Joy Benn, MBA, CPXP, projet manager, patient/family engagement, Minnesota Hospital Assoiation, St.

4 10:45 11 a.m. Break #8 Partnerships Make Safety Possible Joy Benn, MBA, CPXP, projet manager, patient/family engagement, Minnesota Hospital Assoiation, St. Paul, MN; and Lisa Juliar, engagement speialist, Minnesota Alliane for Patient Safety, Minneapolis, MN Person and Family Engagement is a ritial omponent of ensuring that patients/residents/onsumers experiene safe are everywhere. This session will highlight best praties for engaging patients, residents and families in their are through stories of suessful partnerships. Inlude Always, a Minnesota-based approah to inluding patients, residents and families as true partners in the health are system, will highlight urrent data and exiting new work being done to advane engagement efforts aross the state and how onsumers and organizations are responding to the invitation to Inlude Always. #9 Transitions of Care and Reduing Readmissions Kristen Husen, diretor, home are and hospie, CentraCare Health, St. Cloud, MN; Mary Jo Huppert, diretor, are management linial operations, Fairview/HealthEast Care System, St. Paul, MN; and Janelle Shearer, program manager, Stratis Health, Minneapolis, MN This session will desribe a ollaborative foused on the hospital to home transition, for patients who need homeare support. The aim inludes improvement in home health are referral and aeptane of servies, resulting in a redution in readmissions. This session will provide an overview of the ollaborative, share suessful approahes used by both hospitals and home are agenies as they work with patients and families to inrease the aeptane and use of home are servies following hospitalization. It will also highlight tools and resoures developed and tested by the statewide ollaborative in support of this effort. 11 a.m. 12 p.m. General Session: Communiation and Optimal Resolution (CANDOR) Sponsored by CentraCare Health Timothy MDonald, M.D., J.D., president, Martin J. Hatlie, J.D., o- diretor, Center for Open and Honest Communiation, MedStar Institute for Quality and Safety; Washington, D.C. A traditional approah when unexpeted harm ours often follows a demand-and-defend strategy, providing limited information to patients and families, and avoiding diffiult onversations that might involve telling the truth and admitting mistakes.in ontrast, the Communiation and Optimal Resolution (CANDOR) is a truly patient-entered approah that emphasizes early empathi ommuniation of adverse events, provision of early and ongoing peer support to provider staff, learning through human fators-based event review, omplete transpareny and a prinipled, proative method of ahieving a fair resolution for the patient/family and involved health are providers. MDonald and Hatlie will share evidene, best praties and lessons learned in assisting health are organizations assess readiness and integrate a CANDOR approah into their patient safety programs p.m. Lunh Sponsored by the Minnesota Department of Health 1 2 p.m. Breakout Sessions #10 Leadership Culture Aross the Spetrum Stay L. Lee, J.D., CPA, LNHA, hief exeutive offier, Jen Erdmann, R.N., diretor of nursing, Johnson Memorial Hospital, Dawson, MN Critial Aess Hospitals that exel aross national patient safety and quality measurements invariably desribe strong leaders and a ulture that expets and wholeheartedly supports exellene in patient safety, quality and patient experiene. A ollaborative of several suessful mentor hospitals and organizations have gone on a journey towards building a ulture of exellene. Lee and Erdmann will share Johnson Memorial Hospital s experienes and the suessful ways they have reated a ulture of safety and exellene in their health are organization and ommunity whih atively engages their patients, families and staff. #11 Elder Abuse: A Systems-based, Patient Safety Approah to Prevention Katie Behrens, prevention and outreah oordinator, Minnesota Elder Justie Center, St. Paul, MN; Julie Apold, vie president of quality and performane exellene, LeadingAge Minnesota, St. Paul, MN; and Anneliese Peterson, vie president of operations, Walker Methodist, Minneapolis, MN Approximately 1 in 10 Amerians age 60 and older have experiened some form of elder abuse. Reduing instanes of maltreatment (abuse, neglet, and exploitation) of older adults requires a systemati approah to preventing these events before they happen and learning from events when they do our. In this session, presenters will desribe efforts to understand and address the underlying auses of maltreatment and will share a ase study involving abuse and lessons learned about the fators ontributing to the abuse and effetive solutions to address those findings.

2 2:20 p.m. Break #12 Surgial Time Out Proess Tania Daniels, MBA, BAS, vie president, quality and patient safety, Minnesota Hospital Assoiation, St.

Building off of this ampaign, the Minnesota Department of Health and the Minnesota Hospital Assoiation worked together to modify the Minnesota Time Out inorporating safe ulture statements and expand

5 2 2:20 p.m. Break #12 Surgial Time Out Proess Tania Daniels, MBA, BAS, vie president, quality and patient safety, Minnesota Hospital Assoiation, St. Paul, MN; Diane Rydryh, MA, diretor, health poliy, Minnesota Department of Health, St. Paul, MN; and Chelsea Bakken, patient safety and performane exellene oordinator, CentraCare Health-St. Cloud Hospital, St. Cloud, MN The Minnesota Time Out Campaign sought to eliminate wrong site events by providing resoures to ondut effetive time-outs for every patient, every invasive proedure, every time. Building off of this ampaign, the Minnesota Department of Health and the Minnesota Hospital Assoiation worked together to modify the Minnesota Time Out inorporating safe ulture statements and expand it to inorporate standardized elements in the briefing. This presentation will provide an overview of the hanges and new tools and resoures available to redue wrong site, wrong proedure events and will walk through the experiene of a hospital implementing these tools. You will walk away with information on available resoures and tools to redue the number of surgial adverse health events. 2:20 3:30 p.m. Closing Keynote Session: Safety II Sponsored by Stratis Health Matthew Sanlon, M.D., CPPS, professor of pediatris, Medial College of Wisonsin, physiian, Children s Hospital of Wisonsin, Milwaukee, WI Traditional patient safety efforts were designed and implemented under the premise that our systems are well understood, well designed and preditable. Therefore, when things go wrong, individuals are often identified as the ause and fous for developing ations to prevent future harm. Today, we realize that most of preventable health are harm events are due to systems issues that are often overlooked. This session will desribe the need to offer a new approah to safety that helps understand and address systems issues that ontribute to preventable health are harm and provide a pratial model for thinking about systems with suggestions for appliations by safety teams 3:30 p.m. Closing Remarks and Adjourn

6 Conferene Information About the onferene Reigniting Our Passion for Safe Care is the ninth statewide onferene sponsored by the Minnesota Alliane for Patient Safety (MAPS) sine The 2018 MAPS Conferene will disseminate leading edge praties, provide knowledge on ritial topis in safe are and failitate reative and solutionoriented dialogue about how to make health are sustainably and measurably safer in Minnesota. Objetives Reognize trends in safe are to improve safety aross health are settings; Provide strategies and ations for establishing and maintaining a ulture of safety; Demonstrate how organizations have suessfully measured the outomes of their patient safety improvement initiatives; Provide reative and solution-oriented initiatives to make health are safer and more sustainable; Explore opportunities to improve engagement between patients, resident, families and provers for safer are everywhere. Who Should Attend Health are professionals, quality and safety leaders, managers, eduators, patients involved in faility ommittee s or advisory groups and others interested in patient safety aross all health are settings. Registration Registration information about the patient safety onferene an be found at You may register for this program in any of the following ways: By mail: download the registration form at mnpatientsafety.org/2018-maps-onferene and mail to: MAPS Conferene /o Minnesota Hospital Assoiation 2550 University Ave. W., Ste. 350-S Saint Paul, MN By fax: (651) Online: visit log-in and selet Calendar of Events to register. The fee reflets the ost of program development, administration, promotion, faulty expenses, lunh, and break items. MAPS reserves the right to anel or reshedule due to an insuffiient number of registrants or other unforeseen irumstanes. Registration will be aepted on a first-reeived basis. Registration fees, less a $25 anellation fee are refundable if notie is reeived five working days prior to the program date. Registrants unable to attend may send one alternate. No show registrations will be billed. Spae is limited Speial Needs If you have any speial needs that we an aommodate for this program, please ontat MHA s Eduation Department at (651) prior to the event. Aommodations To make reservations all the Minneapolis Marriott Northwest diretly at (763) Please indiate that you are attending the MAPS Conferene when making overnight aommodations. Room rate: $141 standard suite; Cut-off date: Otober 3, Book your room at the Minneapolis Marriott Northwest. Continuing Eduation Opportunities Nurses Contat Hours: This ativity has been designed to meet the Minnesota Board of Nursing ontinuing eduation requirements. A total of up to 12.2 ontat hours will be awarded to those attending this eduational ativity. However, the nurse is responsible for determining whether this ativity meets the requirements for aeptable ontinuing eduation. (Day One 6; Day Two 6.2). Pharmaists: 10 ontat hours have been applied for through the Minnesota Board of Pharmay. Pharmaists must omplete a CEU and program evaluation form at the onlusion of the onferene. Offiial ertifiates of ontinuing eduation will be mailed to attendees after the program. (Day One 5; Day Two 5). Long-Term Care Administrators: 10 Continuing Eduation Units have been applied for through the Minnesota Board of Examiners for Nursing Home Administrators. (Day One 5; Day Two 5). Registration Fee (Does not inlude lodging aommodations) Before Sept. 11 $310 MAPS members $360 Non-members $75 Patient or Resident Volunteer Advisors (per day) After Sept. 11 $395 all attendees $75 Patient or Resident Volunteer Advisors (per day) On-Site $500 All attendees

7 Sponsors Gold Silver Bronze

8 Minnesota Alliane for Patient Safety 2018 Conferene Reigniting Our Passion for Safe Care Name: Title: Faility/Organization: Address: City: State: ZIP: Phone: Fax: Please indiate whih breakout sessions you will be attending (hek one per time slot) Thursday, Ot. 25, a.m. Friday, Ot. 26, :45 10:45 a.m. #1 Understanding and Responding to Dementia-Related Behaviors: A Guide for All Staff Roles #7 Human Fators Engineering: What is it and How Do We Use it? #2 Open Notes #8 Partnerships Make Safety Possible #3 Weaving Together the Critial Components of a Strong and Comprehensive Patient Safety Program #9 Transitions of Care and Reduing Readmissions Thursday, Ot. 25, :15 a.m. 12:15 p.m. Friday, Ot. 26, p.m. #4 Human Centered Design for Performane Improvement #10 Leadership Culture Aross the Spetrum #5 Rae, Raism and Health Inequity: What Can We Do About It? #11 Elder Abuse: A Systems-based, Patient Safety Approah to Prevention #6 Community-Based Care Collaboration Prevents Opioid Abuse #12 Surgial Time Out Proess Method of Payment Chek made payable to Minnesota Hospital Assoiation enlosed VISA MasterCard Amerian Express Card number: Exp. date: Se. ode: ( 3 digit number on bak of ard) Name on ard: 7518

Partnering for Safer Care

Partnering for Safer Care Minnesota Alliane for Patient Safety (MAPS) Conferene: Partnering for Safer Care Ot. 27-28, 2016 Marriott Northwest, Brooklyn Park Keynote speaker: Regina Holliday General session