Strange Strategy and Change. HRO High Reliability Organizing
|
|
|
- Wilfrid Hunt
- 6 years ago
- Views:
Transcription
1 HRO High Reliability Organizing
2 Program 14.00u Dialogue versus Discussion HRO condition 1: Informed culture 14.15u A real life situation: the Intensive Care Unit at the OLVG An introduction to all 4 HRO conditions 14.45u Being mindful HRO condition 2: Heedful relationships and HRO condition3: Shared references 15.15u Brainstorming: HRO experiments HRO condition 4: Redundancy 15.30u Conditions for successful change Applying the 4 HRO conditions in your own working environment 15.45u Ending this workshop on HRO
3 Program 14.00u Dialogue versus Discussion HRO condition 1: Informed culture 14.15u A real life situation: the Intensive Care Unit at the OLVG An introduction to all 4 HRO conditions 14.45u Being mindful HRO condition 2: Heedful relationships and HRO condition3: Shared references 15.15u Brainstorming: HRO experiments HRO condition 4: Redundancy 15.30u Conditions for successful change Applying the 4 HRO conditions in your own working environment 15.45u Ending this workshop on HRO
4 Dialogue versus Discussion Write down what you want to learn in this workshop Describe a situation in your working environment that illustrated your desire to learn exactly this. What is this difficult for you in learning this? Explanation of dialogue versus discussion In groups of three: storyteller, questioner, observer 3 min discussion 3 min dialogue 2 min exchanging observations Sharing of what we discovered
5 Program 14.00u Dialogue versus Discussion HRO condition 1: Informed culture 14.15u A real life situation: the Intensive Care Unit at the OLVG An introduction to all 4 HRO conditions 14.45u Being mindful HRO condition 2: Heedful relationships and HRO condition3: Shared references 15.15u Brainstorming: HRO experiments HRO condition 4: Redundancy 15.30u Conditions for successful change Applying the 4 HRO conditions in your own working environment 15.45u Ending this workshop on HRO
6 Basic conditions Strange Strategy and Change High Reliability Culture HRO condition 1: Informed culture HRO condition 2: Shared references HRO condition 3: Redundancy Mindfulness: being aware and alert Ability to manage the unexpected Excellent results HRO conditie 4: Heedful relations Interventions Principles: 1. Preoccupation with failure 2. Reluctance to simplify 3. Sensitivity to operations 4. Resilience 5. Respect for expertise
7 Being mindful Explaining blamefree and observation/interpretation/judgement Listening to the story of the OLVG
8 Situation 24 available beds 8 intensivists Teaching hospital 130 nurses (that are not all die hards anymore) The question is not anymore: can we keep the patient alive?, but when do we add limitations to the treatment of the patient? ICU: a central department in the hospital Introduction of telemedicine
9 Situation This ICU: Has the ambition to be one of the best ICU s in the Netherlands Keeps innovating and experimenting with new techniques Involving dedicated professionals that started this unit 30 years ago and doctors and nurses from the present generation
10 Why we started to implement HRO We are regarded as a best practice ICU And still, we think we can do better It has something to do with how people interact and we do not know how to improve that
11 Situation Issues are: Only 18/24 available beds can be used Shortage of nurses The results of the Employee Satisfaction Research were alarming: employees are not happy to work here at all Recently two incidents in patient care probably preventable doctors and nurses are restless Some of them feel that they are to blame
12 Situation How to proceed? protocols? punishment? increasing control? A strategy that starts at baseline but is immediately implemented at the bedside
13 Intervention Strategy Step 1. Closing the mental contract Intake with the board of directors Intake with the 8 doctors Intake with the middle management Is everybody in? And with what expectations? Negotiating meeting with doctors and management What result do we want to accomplish together by introducing HRO?
14 Intervention Strategy Step 2. Creating shared references and shared sense of urgency When first introducing HRO there were a lot of doubts, but we had to start somewhere.. Starting meetings with doctors and nurses Nightmare and Dream ICU Practicing in dialogue instead of discussion Practicing in separating observation, interpretation and judgement Creating experiments
15 Intervention Strategy Step 3. Learning by doing experiments Experimenting = possibility to make mistakes and learn from them Doctors and nurses work together in experiments Self organizing without the help of management Manager as coach of the experiment group Practice not to simplify: reflecting and evaluating
16 The HRO experiments Shared references 1.Explaining protocols 2.Knowledge quiz 3.End of life 4.Talking blame free about a situation Redundancy: 5.Time-Out 6.Vliegende keep 7.Blame free evaluation of the day Respect for expertise: 8.Walk a mile in my shoes 9.Frisse blikken spuien 10.Telling stories Focus on operations: 11. To what question is this an answer? 12. Think of your hat, stay on your seat
17 Intervention Strategy Step 4. Collective Sense Making Reflection meetings and evaluation meetings Practice not to simplify Acting AND reflecting Meetings with doctors and managers Coaching the experiments Explaining, sense making and being resilient Think of your hat and stay on your chair
18 Intervention Strategy Step 5. Anchoring HRO Three gangs that keep HRO alive: Content Patterns in interaction Leading HRO starting meeting for new employees Three rounds of HRO experiments each year
19 Resting case How do we keep HRO alive? At this moment there is a HRO-silence at the ICU Starting new experiments Making people enthousiastic about it - again!!! Share the experience and results Giving a huge party for the whole team, with a kick-off for new experiments Working a week with the same colour (team) 13 groups, contains 10 persons of the same colour 3 experiments Your ideas???
20 Results We learned to speak the same language Informed culture: Dialogue instead of discussion Observation, Interpretation, Judgement Checking assumptions Another look at the right information for the right people Focus on mistakes: I am a human being and do not have to be perfect- a very difficult one! Not simplify: No jumping to conclusions and solutions Acting AND reflecting Creating shared references on f.e. protocols and on end of life decisions
21 Results In short: Doctors and nurses together: - Determined what can be improved in this ICU concerning quality of care, patient safety and cooperating - Created experiments to constantly improve - Used their experiences in the experiments to introduce new ways of working that improve alertness of doctors and nurses and therefore improve patient safety
22 Results We are not yet in a situation where all of this is a second nature. There is a great interindividual variability in the sense of urgency and ideas how to progress. The role of management is becoming clear and tranparant. A more open discussion between and within disciplines, but we are not yet at the preferred endpoint.
23 To what question is HRO an answer? HRO is not an answer to creating an even more perfect ICU It is an answer to creating more alertness between doctors, nurses and doctors and nurses in working together. So that they can deal with unexpected events Mistakes will still be made, but doctors and nurses will notice weak signals early and will give strong responses to that weak signals. And that creates better patient safety
24 Program 14.00u Dialogue versus Discussion HRO condition 1: Informed culture 14.15u A real life situation: the Intensive Care Unit at the OLVG An introduction to all 4 HRO conditions 14.45u Being mindful HRO condition 2: Heedful relationships and HRO condition3: Shared references 15.15u Brainstorming: HRO experiments HRO condition 4: Redundancy 15.30u Conditions for successful change Applying the 4 HRO conditions in your own working environment 15.45u Ending this workshop on HRO
25 Being mindful In groups of three: Sharing your observations What HRO principles and conditions do you recognize in the behavior of the people working at the ICU of the OLVG? What is striking in the story to you? What will be unexpected events to the ICU of the OLVG?
26 Program 14.00u Dialogue versus Discussion HRO condition 1: Informed culture 14.15u A real life situation: the Intensive Care Unit at the OLVG An introduction to all 4 HRO conditions 14.45u Being mindful HRO condition 2: Heedful relationships and HRO condition3: Shared references 15.15u Brainstorming: HRO experiments HRO condition 4: Redundancy 15.30u Conditions for successful change Applying the 4 HRO conditions in your own working environment 15.45u Ending this workshop on HRO
27 Brainstorming: HRO experiments New groups of three What experiments would you start at the ICU of the OLVG? What would this experiment look like? What HRO principles and conditions are key in this experiment? Write the experiments down on the wall
28 Program 14.00u Dialogue versus Discussion HRO condition 1: Informed culture 14.15u A real life situation: the Intensive Care Unit at the OLVG An introduction to all 4 HRO conditions 14.45u Being mindful HRO condition 2: Heedful relationships and HRO condition3: Shared references 15.15u Brainstorming: HRO experiments HRO condition 4: Redundancy 15.30u Conditions for successful change Applying the 4 HRO conditions in your own working environment 15.45u Ending this workshop on HRO
29 Conditions for successful change We pause at the 4 HRO conditions. Think back of your own situation. What conditions do you need to negotiate about before you can start with implementing HRO?
30 Program 14.00u Dialogue versus Discussion HRO condition 1: Informed culture 14.15u A real life situation: the Intensive Care Unit at the OLVG An introduction to all 4 HRO conditions 14.45u Being mindful HRO condition 2: Heedful relationships and HRO condition3: Shared references 15.15u Brainstorming: HRO experiments HRO condition 4: Redundancy 15.30u Conditions for successful change Applying the 4 HRO conditions in your own working environment 15.45u Ending this workshop on HRO
31 More about patient safety and HRO? February 14th 2012: Strange Workshop Leave your business card and you will be invited
Shifting from Blame-&-Shame to a Just-and-Safe Culture
Shifting from Blame-&-Shame to a Just-and-Safe Culture Barb Sproll Medication Safety Pharmacist Winnipeg Regional Health Authority 29 May 2018 Conflict of Interest I have no conflicts to disclose. Objectives:
High Reliability Organizations Healing Without Harm by 2014
Please click your mouse or use the enter button to move onto the next slide High Reliability Organizations Healing Without Harm by 2014 1.1 Stand up if You have suffered harm as a patient at a hospital
High Reliability Organizations The Key to Improving Quality and Safety
High Reliability Organizations The Key to Improving Quality and Safety William B Munier, MD, MBA Acting Director Center for Quality Improvement and Patient Safety Agency for Healthcare Research and Quality
Creating a Highly Reliable Health System: the Leadership Challenge. 6 th Annual Patient Safety Symposium Rick Foster, MD
Creating a Highly Reliable Health System: the Leadership Challenge 6 th Annual Patient Safety Symposium Rick Foster, MD April 18, 2013 Moving Toward Zero It may seem a strange principle to enunciate as
TRANSLATING INSTITUTIONAL DATA INTO UNIT SPECIFIC OUTCOME METRICS USING CUSTOMIZED NURSING SCORECARDS
TRANSLATING INSTITUTIONAL DATA INTO UNIT SPECIFIC OUTCOME METRICS USING CUSTOMIZED NURSING SCORECARDS Debra Campbell, BSN, RN, CPHQ Mary Stevie, MS, RN Cincinnati, Ohio Est. 1889 About TCHHN 621 Bed Tertiary
Creating a Culture in Support of Patient Safety
Session: L11 Ms. Ching has nothing to disclose Ms. Derheimer is an employee of the Virginia Mason Institute; a not-for-profit organization that provides education and training in the Virginia Mason Production
Patient Safety is Everyone s Responsibility Tammy Brock, MSN RN CPHRM
Patient Safety is Everyone s Responsibility Tammy Brock, MSN RN CPHRM Objectives Know TJC 2016 National Patient Safety Goals Discuss human factors on patient safety What is your role in patient safety?
Creating High Reliability Organizations. Enhancing the Culture of Safety for Our Patients & Our Organizations
Creating High Reliability Organizations Enhancing the Culture of Safety for Our Patients & Our Organizations OUR TRUST by Dr. Don Berwick Reliability from the Patient s Perspective Don't kill me (no needless
SPC Case Studies Answers
SPC Case Studies Answers Ref: JC Benneyan, RC Lloyd, PE Plsek, Statistical process control as a tool for research and healthcare improvement, Qual. Saf. Health Care 2003; 12:458 464 doi:10.1136/qhc.12.6.458
Engaging Leaders: From Turf Wars to Appreciative Inquiry
Engaging Leaders: From Turf Wars to Appreciative Inquiry Principles of Leadership for a Quality and Safety Culture Harvard Safety Certificate Program 2010 Gwen Sherwood, PhD, RN, FAAN Gwen Sherwood, PhD,
Unit 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
What 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
2/15/2016. 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
ICU Leadership Brussels, January 17-19, 2018
ICU Leadership Brussels, January 17-19, 2018 Wednesday, January 17, 2018 (10h30-18h00) 10.30 Welcome, introduction and review of course materials Co-production and exceptional outcomes: the patient at
The Future of Critical Care Medicine. Neal H. Cohen, MD Mark Eisner, MD Hildy Schell-Chaple, RN Michael West, MD
The Future of Critical Care Medicine Neal H. Cohen, MD Mark Eisner, MD Hildy Schell-Chaple, RN Michael West, MD Future of Critical Care Medicine What is Critical Care? The Critical Issues in Critical Care
From 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
2018 DOM HealthCare Quality Symposium Poster Session
Winner - Outstanding Faculty Project Author Hillary Lum, MD, Faculty Division/Department Geriatric Medicine / Department of Medicine UCHealth Patient use of a Medical Power of Attorney via My Health Connection
2. Why Applying Human Factors Is Important For Patient Safety
PATIENT SAFETY 436 TEAM 2. Why Applying Human Factors Is Important For Patient Safety Objectives: Understand Human Factors And Its Relationship To Patient Safety Define The Meaning Of The Term Human Factors
Invigorating Nursing Peer Review through Integration of Just Culture Human Factors and Principles
Invigorating Nursing Peer Review through Integration of Just Culture Human Factors and Principles Jane S. Braaten, PhD, RN, CNS/ANP, CPPS Castle Rock Adventist Hospital Castle Rock, CO Cynthia Oster PhD,
10/21/2013. Hospitals as Highly Reliable Organizations. Examples from Intensive Care Settings. Some Statistics to Ponder - USA
Hospitals as Highly Reliable Organizations Daniel L. Cohen MD, FRCPCH, FAAP International Medical Director/Datix Ltd., UK & Malcolm Daniel MB ChB, FRCP, FRCA, FICM Consultant in Anaesthesia and Intensive
M2 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
COOK 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:
Emergency Department Patient Experience Survey Highlights
Emergency Department Patient Experience Survey Highlights www.hqca.ca April 2008 Albertans get emergency and urgent care services in many different ways. People in cities sometimes go to emergency departments
Baptist Health Nurse Leader Competency Model
Baptist Health Nurse Leader Competency Model Strategic Visionary Systems Thinking Quality Care and Performance Improvement Fiscal and Management Excellence Management of Self and Others 1 - Strategic,
Critical Care, Critical Choices: The Case for Tele-ICUs in Intensive Care
Critical Care, Critical Choices: The Case for Tele-ICUs in Intensive Care April 29, 2011 Waltham, MA Presented by Lisa Payne Simon, MPH Cheryl H. Dunnington, RN, MS 1 FAST Initiative Overview 2004-2010
Appendix G: The LFD Tool
Appendix G: The LFD Tool What is a defect? A defect is any event or situation that you don t want to repeat. This could include an incident that caused patient harm or put patients at risk for harm, like
Sharp 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
TeleICU And What It Means To You
Vanderbilt Department of Anesthesiology TeleICU And What It Means To You Dr. L. Weavind MBBCh Associate Professor Anesthesia and Surgery Director Critical Care Fellowship Vanderbilt University Former Director
Chasing Zero The Journey to Rural Hospital High Reliability
1 Chasing Zero The Journey to Rural Hospital High Reliability Clint MacKinney, MD, MS Clinical Associate Professor College of Public Health University of Iowa clint-mackinney@uiowa.edu 2 Chasing Zero A
May 10, Empathic Inquiry Webinar
Empathic Inquiry Webinar 1.Everyone is muted. Press *6 to mute yourself and *7 to unmute. 2.Remember to chat in questions! 3.Webinar is being recorded and will be posted on ROOTS Portal and sent out via
ATTENTION ALL C.N.A S
ATTENTION ALL C.N.A S October s monthly Education Manual will not be the usual booklet. You will find a different handout with required reading and a post test. This handout will meet your required units
Fall Prevention at SMH
Fall Prevention at SMH All hospitalized patients are at Risk to fall. The Fall risk assessment, located on the Nursing assessment flow sheet, helps to identify who is most at risk for falling. The fall
Renal cancer surgery patient experience February 2014-February 2015
Renal cancer surgery patient experience February 2014-February 2015 The specialist renal cancer team have set high patient experience as one of the key objectives of the specialist renal cancer centre.
TIME OUT! A Patient Safety Strategy. Col Doug Risk, Lt Col Kelli Mack USAF Dental Evaluations & Consultation Service
TIME OUT! A Patient Safety Strategy Col Doug Risk, Lt Col Kelli Mack USAF Dental Evaluations & Consultation Service Disclosures The opinions expressed in this presentation are those of the authors and
Building a High-Performance team in the Pediatric Medical Home Xavier Sevilla M.D. FAAP Whole Child Pediatrics MCRHS Inc.
Building a High-Performance team in the Pediatric Medical Home Xavier Sevilla M.D. FAAP Whole Child Pediatrics MCRHS Inc. Whole Child Pediatrics Whole Child Pediatrics Opened November 2007 Using the Principles
How to deal with Emergency at the Operating Room
How to deal with Emergency at the Operating Room Research Paper Business Analytics Author: Freerk Alons Supervisor: Dr. R. Bekker VU University Amsterdam Faculty of Science Master Business Mathematics
Code Sepsis: Wake Forest Baptist Medical Center Experience
Code Sepsis: Wake Forest Baptist Medical Center Experience James R. Beardsley, PharmD, BCPS Manager, Graduate and Post-Graduate Education Department of Pharmacy Wake Forest Baptist Health Assistant Professor
180 Feedback Results for Sample Nurse Leader
180 Feedback Results for Sample Nurse Leader March 24, 2018 2018 by American Organization of Nurse Executives 1 About This Report Sample Nurse Leader This report contains a summary of your 180-Degree Feedback
Medical Assistants: Embracing New Roles
Summit 2011 LEARN SHARE TRANSFORM Medical Assistants: Embracing New Roles Bowdoin Street Health Center/ Beth Israel Deaconess Medical Center Fran Azzara, BSN, MPH Operations Manager Session 1C March 7,
Making it safe for acutely ill patients - a whistlestop tour of medical error & patient harm
Making it safe for acutely ill patients - a whistlestop tour of medical error & patient harm Sara Barton Acute Physician Salford Royal NHS Foundation Trust What is medical error? Medical errors can be
Drivers of HCAHPS Performance from the Front Lines of Healthcare
Drivers of HCAHPS Performance from the Front Lines of Healthcare White Paper by Baptist Leadership Group 2011 Organizations that are successful with the HCAHPS survey are highly focused on engaging their
Culture of Safety: What s in Your Toolbox?
Culture of Safety: What s in Your Toolbox? Kathy Ghomeshi, PharmD, BCPS Medication Safety Specialist Victoria Serrano Adams, PharmD, FASHP, FCSHP Director of Pharmaceutical Services UCSF Medical Center
WORKING PAPER SERIES
College of Business Administration University of Rhode Island William A. Orme WORKING PAPER SERIES encouraging creative research Creating High Reliability Organizations Using Mindfulness Douglas Hales
Mary Baum President & CEO BA&T September 18, 2015
Mary Baum President & CEO BA&T September 18, 2015 Objective Why patient safety is so difficult to solve? The problem remains Advances in clinical workflow A collaborative approach Metrics matter Just start.
A 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
Washington Patient Safety Coalition December 10, 2014
Innovating the RCA: Root Cause Analysis & Just Culture Washington Patient Safety Coalition December 10, 2014 Andrea Halliday, MD Interim Patient Safety Officer, PeaceHealth David Allison, CPHRM Interim
Yoder-Wise: Leading and Managing in Nursing, 5th Edition
Yoder-Wise: Leading and Managing in Nursing, 5th Edition Chapter 02: Patient Safety Test Bank MULTIPLE CHOICE 1. In an effort to control costs and maximize revenues, the Rehabilitation Unit at Cross Hospital
MHA Keystone Center Overview. Brittany Bogan, FACHE, CPPS Vice President, Patient Safety and Quality
MHA Keystone Center Overview Brittany Bogan, FACHE, CPPS Vice President, Patient Safety and Quality MHA Family of Companies Michigan Health & Hospital Association 501(c)6 Hospital Purchasing Service Michigan
Wired to Save Lives: A Virtual Hospital Experience
Wired to Save Lives: A Virtual Hospital Experience Donald J. Kosiak, MD, MBA, FACEP, CPE Vice President for Medical Development Thursday, March 3 rd -- 11:30am Conflict of Interest Donald Kosiak, MD Has
Profit = Price - Cost. TAKT Time Map Capacity Tables. Morale. Total Productive Maintenance. Visual Control. Poka-yoke (mistake proofing) Kanban.
GPS Mod 22 7 Flows of Medicine MUDA MUDA Cost Reduction By Eliminating Waste Just-in-Time Profit = Price - Cost GPS Depth Study NVA/VA- Functions/Mgrs R e d e p l o y m e n t Jidoka (human automation)
Practical 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
The medical office survey on patient safety culture MOSPSC!
The medical office survey on patient safety culture MOSPSC! Opinions and views! of EQuiP network General Practitioners! Dr Isabelle DUPIE! Dr André NGUYEN VAN NHIEU! EQuiP Conference Dublin 4 th March
Lakota Health System: eicu Pilot for Pine Ridge Indian Health Services Hospital
Lakota Health System: eicu Pilot for Pine Ridge Indian Health Services Hospital MMI 404 Health Enterprise Operations Group 1 Rhona Banayat Ralph Garcia Nicole Hawkins Mike Nowak November 20, 2011 Presentation
From Data To Action. Putting Data to Work in Today s Hospital
From Data To Action Putting Data to Work in Today s Hospital Growing Challenges In today s uncertain environment, hospitals face many pressures. For some, future financial sustainability is becoming a
From the Military to Civilian Medicine and Beyond: A Locum Tenens Physician's Career Path
Transcript Details This is a transcript of an educational program accessible on the ReachMD network. Details about the program and additional media formats for the program are accessible by visiting: https://reachmd.com/programs/clinicians-roundtable/from-the-military-to-civilian-medicine-and-beyonda-locum-tenens-physicians-career-path/7004/
Delivering 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
Program of Instruction Course Syllabus
Program of Instruction Course Syllabus Course Title: Advanced Fire Officer Blended / NFPA 1021 Fire Officer II Course : 120 Hours Phase 1-40 hours Phase 2-80 hours Program: Fire Officer Course Prerequisites:
Sepsis The Silent Killer in the NHS
Sepsis The Silent Killer in the NHS Kate Beaumont, Trustee, UK Sepsis Trust Nurse Director The Learning Clinic Director QGi Ltd Former Head of Patient Safety and lead for deterioration, National Patient
Presentation to the Maryland Patient Safety Center 14 th Annual Patient Safety Conference, Baltimore, Maryland Rosemary Gibson, Author, Wall of
Presentation to the Maryland Patient Safety Center 14 th Annual Patient Safety Conference, Baltimore, Maryland Rosemary Gibson, Author, Wall of Silence Senior Advisor, The Hastings Center April 13, 2018
Pursuit of the Perfect Patient Experience: How Virginia Mason Became a High Performing Healthcare System
Pursuit of the Perfect Patient Experience: How Virginia Mason Became a High Performing Healthcare System Sarah Patterson, Executive VP & COO The King s Fund Annual Conference November 13, 2014 Virginia
Focus 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
Understanding 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)
Reducing the Risk of Wrong Site Surgery
Joint Commission Center for Transforming Healthcare Reducing the Risk of Wrong Site Surgery Wrong Site Surgery Project Participants The Joint Commission s Center for Transforming Healthcare aims to solve
Creating A Centralised Operations Centre
Creating A Centralised Operations Centre Paul B. Davenport RN, BSN, NREMT-P(ret.), MBA, CMTE Carilion Clinic, Roanoke, VA US Multi-Hospital Healthcare System 2 Physician Group 600 + Hospitals 6 Practice
A question? Call us now!
% 100% of all assistance missions safely and successfully completed for over 25 years, together with our network of experienced professionals that we select, motivate and manage. Mega Assistance demands
Improving Patient Experience, Safety and Progression through Care Model Redesign & Lean Management
Improving Patient Experience, Safety and Progression through Care Model Redesign & Lean Management Michelle Cline, RN, MSN, Care Model Redesign Manager Donna Litwinski, PT, Master Lean Fellow April 2018
Resilience Approach for Medical Residents
Resilience Approach for Medical Residents R.A. Bezemer and E.H. Bos TNO, P.O. Box 718, NL-2130 AS Hoofddorp, the Netherlands robert.bezemer@tno.nl Abstract. Medical residents are in a vulnerable position.
AGGRESSIVE BEHAVIOR TOOLKIT WSHA & ASHNHA PARTNERSHIP FOR PATIENTS PRESENTED BY: COURTNEY ULRICH
AGGRESSIVE BEHAVIOR TOOLKIT WSHA & ASHNHA PARTNERSHIP FOR PATIENTS PRESENTED BY: COURTNEY ULRICH HIIN AND PARTNERSHIP FOR PATIENTS The Partnership for Patients initiative is a public-private partnership
Session 93AB Creating and Sustaining a Culture of Innovation to Achieve Zero Events of Preventable Harm
Prepared for the Foundation of the American College of Healthcare Executives Session 93AB Creating and Sustaining a Culture of Innovation to Achieve Zero Events of Preventable Harm Presented by: Brent
Pursuing the Triple Aim: CareOregon
Pursuing the Triple Aim: CareOregon The Triple Aim: An Introduction The Institute for Healthcare Improvement (IHI) launched the Triple Aim initiative in September 2007 to develop new models of care that
Safety Measurement, Monitoring & Strategies
Safety Measurement, Monitoring & Strategies Jonkoping Microsystem Festival Scientific Day March 2016 Charles Vincent Professor of Psychology University of Oxford Lead Oxford AHSN Patient Safety Collaborative
COMPREHENSIVE EARLY GOAL DIRECTED THERAPY IN SEPSIS ROCHESTER GENERAL. Sepsis Treatment Order Sets Sepsis Treatment Order Sets
Publication Year: 2013 COMPREHENSIVE EARLY GOAL DIRECTED THERAPY IN SEPSIS ROCHESTER GENERAL Summary: An organized accepted approach to sepsis recognition, early management in the ED including specific
ILLUSTRATION BY STEPHANE MANEL
+A ILLUSTRATION BY STEPHANE MANEL AN INTERVIEW WITH BERNARD J. TYSON, CHAIRMAN AND CEO OF KAISER PERMANENTE SERVING PATIENTS AS CONSUMERS BERNARD J. T YSON is chairman and CEO of Kaiser Permanente, a health
Strategies to Reduce Readmissions, Sepsis, and Health-Care Associated Infections
C10 This presenter has nothing to disclose Strategies to Reduce Readmissions, Sepsis, and Health-Care Associated Infections David Renfro, MS, RN NE BC Kelly Farnam, BSN, RN Gloria Martinez, MS, RN, NEA
Coaching High-Performing Teams. Serving Trumps Fixing! Nik Kalantjakos
Coaching High-Performing Teams Serving Trumps Fixing! Nik Kalantjakos Coaching High-Performing Teams Abstract High-performing teams deliver amazing results. They discover what they want. They 'see it'.
CAPT Sheila Patterson First Female Commanding Officer of NSWCDD,
CAPT Sheila Patterson First Female Commanding Officer of NSWCDD, 2007-2010 Introduction MUSIC Welcome to the Dahlgren Centennial Celebration A Century of Innovation. We hope that this and our many other
NCQC PSO Safe Tables Fall Prevention July 2016
NCQC PSO Safe Tables Fall Prevention July 2016 Background Role of a PSO Share Learn Improve Protection under the and Quality Improvement Act of 2005 It s like Vegas Safe Table Objectives Support our commitment
Self-assessment surveys details & definitions
Self-assessment surveys details & definitions Completing the Paradigm self assessment surveys is the very first step in achieving the Paradigm Award. Only organizations who complete the self assessment
Becoming a High Reliability Organization Operational Advice for Hospital Leaders
Becoming a High Reliability Organization Operational Advice for Hospital Leaders Prepared for: Agency for Healthcare Research and Quality U.S. Department of Health and Human Services 540 Gaither Road Rockville,
SITE APPLICABILITY This practice applies to all pediatric patient care areas that have been designated by your health authority.
GUIDELINE PURPOSE To provide guidance and direction for the use of the Pediatric Early Warning System (PEWS). The PEWS system supports the recognition, mitigation, notification, and response to the pediatric
Improving hand hygiene compliance with innovative technology solutions
GE Healthcare CASE STUDY Performance Solutions: Patient Safety Improving hand hygiene compliance with innovative technology solutions Virtua Memorial is a 433-bed, full-service regional medical center
End of life care in the acute hospital environment: Family members perspectives. Jade Odgers Manager Grampians Regional Palliative Care Team
End of life care in the acute hospital environment: Family members perspectives. Jade Odgers Manager Grampians Regional Palliative Care Team Why? How does a terminally ill patient with clearly documented
Ways to Improve Job Satisfaction for Your Home Health and Hospice Clinicians
3 Ways to Improve Job Satisfaction for Your Home Health and Hospice Clinicians 1 Reduce after-hours homework and give them a better work/life balance As recently as 10 years ago, most patient record keeping
Talking to Your Family About End-of-Life Care
Talking to Your Family About End-of-Life Care Sharing in significant life events during both happy and sad occasions often strengthens our bond with family and close friends. We plan for weddings, the
9/15/2017. Nursing Management Congress 2017 Interruptions in Clinical Practice. Interruptions in Clinical Practice. Review of the Literature
Nursing Management Congress 2017 Interruptions in Clinical Practice Elizabeth A. Duthie, RN, Ph.D., CPPS Director of Patient Safety at Montefiore Health System Interruptions in Clinical Practice The speaker
Follow-up on Blood Pressure Protocols. September 20, 2017
Follow-up on Blood Pressure Protocols September 20, 2017 2 Welcome and Introductions Please type in the chat: Your geographical location What health news are you paying attention to? 3 HealthInsight Cardiac
The Health Care Improvement Foundation 2015 Delaware Valley Patient Safety and Quality Award Entry Form 1. Hospital Name Magee Rehabilitation
The Health Care Improvement Foundation 2015 Delaware Valley Patient Safety and Quality Award Entry Form 1. Hospital Name Magee Rehabilitation 2. Title Of Initiative Innovations to Stop Pressure Ulcers
Chapter F - Human Resources
F - HUMAN RESOURCES MICHELE BABICH Human resource shortages are perhaps the most serious challenge fac Canada s healthcare system. In fact, the Health Council of Canada has stated without an appropriate
Applying Documentation Principles. 1. Narrative documentation of client care events will be done where in the client s record?
MODULE 5 QUIZ Applying Documentation Principles 1. Narrative documentation of client care events will be done where in the client s record? a. Physician s orders b. Personal directive c. Progress notes
1/8/2018. Chapter 55. End-of-Life Care
Chapter 55 End-of-Life Care Some deaths are sudden; others are expected. Health team members see death often. Death and dying mean helplessness and failure to cure. Your feelings about death affect the
Guidance for using the Dewing Wandering Risk Assessment Tool (Version 2 - September 2008)
Guidance for using the Dewing Wandering Risk Assessment Tool (Version 2 - September 2008) This guidance and the risk assessment tool are not to be altered in any way. However, teams can add additional
The 5 Steps to Same Day Access
Joy Fruth, MSW Lead Process Change Consultant MTM Services The 5 Steps to Same Day Access Speaker Name Title Presented Organization By: What is Same Day Access? An engagement strategy whereby organizations
Human Factors. Frank Federico, RPh. This presenter has nothing to disclose.
Human Factors Frank Federico, RPh This presenter has nothing to disclose. 25 February 2015 Culture Learning System Improvement and Measurement Transparency Continuous Learning Accountability Teamwork &
Annual Complaints Report 2014/15
Annual Complaints Report 2014/15 1.0 Introduction This report provides information in regard to complaints and concerns received by The Rotherham NHS Foundation Trust between 01/04/2014 and 31/03/2015.
E-Learning Module B: Assessment
E-Learning Module B: Assessment This module requires the learner to have read chapter 3 of the CAPCE Program Guide and the other required readings associated with the topic. See the CAPCE Program Guide
Fault Tree Analysis (FTA) Kim R. Fowler KSU ECE February 2013
Fault Tree Analysis (FTA) Kim R. Fowler KSU ECE February 2013 Purpose for FTA In the face of potential failures, determine if design must change to improve: Reliability Safety Operation Secondary purposes:
You have joined the CUSP Communication & Teamwork Tools Informational Session!
You have joined the CUSP Communication & Teamwork Tools Informational Session! The session will begin shortly. To access the audio for the session, Dial: 800-977-8002, Participant code 083842# Registrants
Collaboration and Coordination in the MRICU: An Interprofessional Approach to Implementation of a Daily Review of Sedation Strategy, Liberation
Collaboration and Coordination in the MRICU: An Interprofessional Approach to Implementation of a Daily Review of Sedation Strategy, Liberation Potential and Mobility Plan Amy Dean, MS, RN, CCRN Kristin
Outline. Disproportionate Cost of Care. Health Care Costs in the US 6/1/2013. Health Care Costs
Outline Rochelle A. Dicker, MD Associate Professor of Surgery and Anesthesia UCSF Critical Care Medicine and Trauma Conference 2013 Health Care Costs Overall ICU The study of cost analysis The topics regarding
When words and actions matter most: The Case for CANDOR
January 20, 2017 When words and actions matter most: The Case for CANDOR Timothy B McDonald, MD Director, Center for Open and Honest Communication in Healthcare MedStar Health, Institute for Quality and