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 speakers: Mark Graber, MD, Dorothy Sisneros and Barbara Balik 20 eduational breakout sessions

7:30 8:30 a.m. Registration Thursday, Ot. 27 8:30 8:40 a.m. Welome and Opening Remarks 8:40 9:40 a.m. Opening Keynote Address: Quality and Patient Safety Regina Holliday, author, artist, speaker, patient advoate, founder of The Walking Gallery, Grantsville, MD In this opening presentation, Holliday will share her experiene of aring for her husband and his struggle to get appropriate are. Fred lost his life to aner but never lost hope that patients and aregivers an help make the system better for other families. Baked by her own patient and aregiving experienes, Holliday will address ways of improving the quality of health are delivery as well as ways to enhane patient safety. 9:45 10:45 a.m. General Session: Sharing Our Stories Expanding the Diagnosti Team Andrew Olson, M.D., FACP, FAAP, assistant professor, diretor, sub-internship in Critial Care Clerkship, University of Minnesota Medial Shool; Phillip Kibort, M.D., MBA, vie president of medial affairs and hief medial offier, Children s Hospitals and Clinis of Minnesota; Dan Berg and Welome Jerde, Minneapolis, MN This session will fous on methods to improve the diagnosti proess through sharing the story of one loal Minnesota family s tragi experiene with diagnosti error. This will be a failitated interview foused on analyzing where the diagnosti proess broke down and what hanges an be made to avoid suh errors in the future. 10:45 11:10 a.m. Break 11:10 a.m. 12:10 p.m. Breakout Sessions 12:10 1:10 p.m. Lunh #1 The New Diagnosti Team Dotors, NPs, PAs, Nurses and THE PATIENT Mark Graber, M.D., FACP, senior fellow, president and founder of Soiety to Improve Diagnosis in Mediine, Stony Brook, NY This session will disuss the new reommendations from the Institute of Mediine report Improving Diagnosis in Health Care on working as a diagnosti team. The role that patients and nursing staff an play will be emphasized. Pathology and radiology have drifted away from the team and need to be brought bak. The role that the eletroni medial reord plays in advaning and hindering teamwork and diagnosis will be reviewed. #2 Lessons Learned from a Traumati Event Paul Harris, senior vie president and general ounsel, CentraCare Health, St. Cloud, MN, and Kristina Nelson, diretor of surgial are unit, St. Cloud Hospital, St. Cloud, MN Hospitals have been plaes of healing, but in reent years have also been identified as plaes of risk, with the inidene of violent episodes inreasing aross the state of Minnesota. Learn from the experiene of one hospital about proative interventions to mitigate the risks of violene as well as strategies to implement after an ative threat event has taken plae. #3 Patient-Instigated Parkinson s Mediation Improvement Projet: A Suess Story Ron Kitzmann, RPH, MBA, diretor, pharmay, Park Niollet Methodist Hospital, St. Louis Park, MN, and Joan Gardner, RN, BSN, nurse liniian, Park Niollet Methodist Hospital, St. Louis Park, MN The Patient-Family Advisory Committee suggested a projet to improve timeliness and auray of administration of levodopa starting in the emergeny department and going through the system. Clini and hospital nursing, pharmay, emergeny department and medial staff representatives ollaborated to make improvements. Hear about the multiple strategies implemented to ontinue improvement. #4 Transending Burnout: SurTHRIVING in Changing Times Linda Shell, DNP, MA, RN, orporate diretor, eduation, Volunteers of Ameria, Eden Prairie, MN Health are is ever-hanging and filled with hallenges and haos, often resulting in depression, lost work and burnout. Researh indiates when SurTHRIVE skills are inreased, one not only survives in hanging environments, but an SurTHRIVE, resulting in inreased work performane, job satisfation and improved outomes. This workshop disusses the onept of SurTHRIVE skills and provides pratial tips.

1:15 2:15 p.m. Breakout Sessions 2:15 2:40 p.m. Break #5 Promoting Health Through Happiness Community Resilieny Corey L. Martin, M.D., diretor of medial affairs, Buffalo Hospital, Buffalo, MN A first-of-its-kind study was reently launhed in two ommunities, Buffalo and Montiello, to help raise the level of happiness and resilieny. This study will fous on how resilieny an be learned and how it affets the overall health efforts in eah ommunity. This program will fous on both the ollaboration of the two ommunities and the results of the program as it tries to boost the overall mental and physial health of their ommunities. #6 Moving Patient Safety Forward through Measurement Jennifer Lundblad, Ph.D., president and CEO, Stratis Health, Minneapolis, MN Patient safety is onsistently a high priority for health are delivery organizations and for patients and families. However, hospital safety measures urrently reported at state and national levels don t provide a omprehensive piture for patients or hospitals. The Hospital Quality Reporting Steering Committee has developed a patient safety omposite measure. Engage in a lively disussion about using measurement to advane patient safety. #7 When EHRs Cause Patient Harm: Lessons from Malpratie Trish Lugtu, B.S., CPHIMS, CHP, assoiate diretor, researh, MMIC, Minneapolis, MN Eletroni healthare reords (EHRs) signifiantly improve patient safety and quality and oasionally ause harm. This session fouses on the high severity patient harm that results diretly from EHR fators. Learn about EHR-related fators through malpratie data and ase studies; explore barriers that ontribute to breakdowns and a simplified approah for effetively reduing risk of related harm. #8 Embrae Your Googling Patients Andrew Olson, M.D., FACP, FAAP, assistant professor, diretor, sub-internship in Critial Care Clerkship, University of Minnesota Medial Shool, Minneapolis, MN Beause patients and families have unpreedented aess to health information, health are providers must adapt to helping patients proess and refine this information instead of simply providing information. This session will fous on strategies to expand the diagnosti team to inlude patients and families to improve the health are proess. 2:40 4 p.m. General Session: Diagnosti Error in Mediine The Next Imperative for Patient Safety Mark Graber, M.D., FACP, senior fellow, president and founder of Soiety to Improve Diagnosis in Mediine, Stony Brook, NY Diagnosti error may be the largest unaddressed problem in patient safety today, in all health are settings. Graber will review findings from the Institute of Mediine report Improving Diagnosis in Health Care on the inidene and etiology of the problem, and steps that liniians, patients and health are organizations ould take to begin addressing the problem. Friday, Ot. 28 8:30 9:45 a.m. General Session: Communiation Essentials for Patient- and Family-Centered Care Dorothy Sisneros, M.S., MBA, partner, senior vie president, lient servies, Language of Caring, Phoenix, AZ We annot engage patients and families and provide truly patient- and family-entered are without patientand family-entered ommuniation. Our ommuniation needs to extend beyond the tasks and ativities at hand to soliit, honor and address patients preferenes, needs and onerns. Sisneros will define patient- and family-entered ommuniation, desribe essential skills and identify strategies for helping employees, patient and family advisors and physiians strengthen their skills and apply them to build trusting relationships, redue patient and family anxiety and strengthen emotional support. 10 11 a.m. Breakout Sessions #9 Teaming Up to Prevent Biologial Speimen Handling Errors Susan Noaker, Ph.D., LP LLC, projet manager, surgial servies, Fairview Health Servies, Minneapolis, MN and Deborah Axmaher, RN, MSN, MBA, CNOR, diretor-perioperative and endosopy servies, Fairview Health Servies, Minneapolis, MN A system network team redesigned proesses to redue errors in the management of biologial speimens in the operating room. A failure modes and effets analysis assessed risk at eah proess step. The new proedures resulted in a 70 perent derease in the risk of speimen mismanagement. Fairview Health Servies reeived a National Patient Safety Foundation award for this work. Learn how they takled this important initiative.

11 11:15 a.m. Break 11:15 a.m. 12:15 p.m. Breakout Sessions 12:15 1:15 p.m. Lunh #10 Evidene-Based Care Delivery: Development and Diffusion of Systemwide Best Praties Anna Klekner, MPH, Ph.D., evidene-based pratie onsultant, and Tiffany Grandhamp, implementation pratie onsultant, Allina Health, Minneapolis, MN Allina Health has established an evidene-based are delivery system to support linial guideline development, ommuniation, implementation and monitoring. There are three omponents: the Allina Health Evidene-Based Deision-Making Model, the Allina Health Diffusion Model and an evidene-based are delivery dashboard for traking multiple outomes. Two systemwide best pratie efforts will be featured. #11 Strengthening Community Partnerships: Post-Disharge Firefighter Visits Steve Koering, fire hief, St. Louis Park Fire Department, St. Louis Park, MN, and Linda Bauermeister, MAL, BSN, RN, senior diretor of home are, hospie and population health, Park Niollet, St. Louis Park, MN Learn how emergeny medial tehniians from the St. Louis Park Fire Department and the are integration team at Park Niollet Methodist Hospital ollaborated to develop proedures and outome metris to improve the transition from hospital to home. The program has resulted in redued hospital readmissions, improved outomes and high patient satisfation. #12 Improving Provider/Patient Relationships and Diagnosti Quality Through Deliberative Patient Engagement Larry Pennings, assoiate diretor, and Paul Rokway, program diretor, The Jefferson Center, St. Paul, MN The Jefferson Center has onduted researh on reduing diagnosti error and improving patient/provider ommuniation through deliberative patient engagement to generate patient-entered strategies and reommendations for improving diagnosti quality. Explore steps providers and are systems an take to implement reommendations in their are settings, inentives enouraging adoption of these reommendations and additional opportunities to expand patient engagement in safety efforts. #13 Using Clinial and Cultural Change Interventions to Redue CAUTI Susan Klammer, MPH, quality/patient safety projet oordinator, Minnesota Hospital Assoiation, St. Paul, MN, and Staie Urbanik, MSN, RN, diretor of nursing, Essentia Health-St. Mary s Oak Crossing, Detroit Lakes, MN Long-term are organizations ahieved a signifiant redution in CAUTI through implementing the AHRQ Safety Program for Long-Term Care: CAUTI. Learn about the program and hear how a partiipating faility used the framework and toolkit to shift ulture and redue or eliminate CAUTI. #14 Respeting Ourselves and Our Patients: Improving Patient Safety by Improved Handling of Violent Patients Timothy Morgenthaler, M.D., hief patient safety offier, professor of mediine, Mayo Clini, Rohester, MN Health are workers experiene the most nonfatal workplae violene ompared to other professions. Reent studies suggest that 20-40 perent of physiians and 20-80 perent of nurses will experiene episodes of violene initiated by patients, families or visitors over their areer. Learn how the Mayo Clini Violent Patient Handling Program is designed to respet both staff and patient safety. #15 Exploring Patient and Family Engagement Aross Minnesota Catherine Shramm, MHA, projet onsultant, Minnesota Alliane for Patient Safety, Minneapolis, MN Visit the newest tools and resoures to advane patient/resident/lient and family engagement aross are settings in Minnesota. Explore the new loal, virtual ommunity designed to support and advane patient and family engagement to improve safety and are quality. Experiene stories of tried and true praties and hallenges enountered by organizations and those they served. #16 Designing for Mediation Safety Steve Meisel, Pharm.D., CPPS, diretor of patient safety, Fairview Health Servies, Minneapolis, MN Mediation safety is a high priority, but often onfounded by ambiguous definitions and the lak of a standard national metri. Safety improvement efforts are often taken in reation to internal and external events. In this session, learn how one health system established a oneptual framework and organizational model for approahing mediation safety. Measures of suess will be explained and reviewed.

1:15 2:15 p.m. Breakout Sessions 2:15 2:30 p.m. Break #17 Using LEAN A3 Problem-Solving as a Proative Proess to Improve Patient Safety Mihael Goleski, RT (R), MBA, CPHQ, radiology manager; Raegan Sipe, BSN, RN, CEN, linial are supervisor, and Jean Kohs, R.Ph., CPHQ, Hennepin County Medial Center, Minneapolis, MN The patient safety team at Hennepin County Medial Center implemented a suessful Good Cath Reognition Program to enourage near-miss safety event reporting by frontline staff. The team addressed near-miss events using LEAN A3 methodology. This session details an effetive A3 projet that signifiantly redued the risk for mediation errors in the emergeny department. #18 Living Safely in the Community: Children and Adults with Mental Illness Sue Abderholden, MPH, exeutive diretor, and Donna Fox, diretor of adult programming and suiide prevention, National Alliane on Mental Illness Minnesota, St. Paul, MN In this session you will learn about the best praties for disharge planning for hildren and adults with mental illnesses. Explore how to engage families in reating safe spaes and risis plans. Learn about means restrition. #19 Addressing the Opioid Crisis through Evidene-Based Pain Assessment and Management Audrey Hansen, BSN, M.A., PMP, projet manager, health are onsultant, Institute for Clinial System Improvement, Minneapolis, MN, and Joseph Biano, M.D., family mediine/primary are, Essential Health Ely Clini, Ely, MN Learn about the new Institute for Clinial Systems Improvement guideline for improving aute and hroni pain management, inluding opioids. This guideline fouses on involving patients to improve funtioning, enhane quality of life and derease pain. Hear about an effetive hroni pain management program that provides safe and respetful management of opioids for hroni pain. #20 Partnering with Patients in Strategi Organizational Safety Work Catherine Shramm, MHA, projet onsultant, Minnesota Alliane of Patient Safety, Minneapolis, MN and Lisa Juliar, patient advisor, Minnesota Hospital Assoiation, St. Paul, MN Partnering with patients, residents and families for the safest are is one of the eight National Patient Safety Foundation reommendations. Learn from experiened organizations about ways to deepen partnerships with patients and residents in the strategi work to advane patient safety. 2:30 3:30 p.m. Closing Keynote Session: Joy in Partnerships: Patients and Teams Barbara Balik, RN, Ed.D., speaker, partner, Aefina Partners, Albuquerque, NM Team members in all roles an ahieve joy in work and energized partnerships with patients. Safe are, healthy are environments and joy in work ome through thriving partnerships. Learn about transformational leadership praties that ontribute to thriving partnerships that are vital for ahieving joyful, patient-entered are environments. 3:30 p.m. Closing Remarks and Adjourn

Conferene Information About the onferene Partnering for Safer Care is the eighth statewide onferene sponsored by the Minnesota Alliane for Patient Safety (MAPS) sine 2002. The 2016 MAPS Conferene will disseminate leading edge praties, provide knowledge on ritial topis in safe are and failitate reative and solution-oriented 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 everywhere; Explore opportunities to improve engagement between patients, residents, families and providers for safe are everywhere. Who Should Attend Health are professionals, quality and safety leaders, managers, eduators, patients involved in faility ommittees 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 www.mnpatientsafety.org You may register for this program in any of the following ways: By mail: (please make heks payable to Minnesota Hospital Assoiation) download the registration form at http://www. mnpatientsafety.org/events/2016-conferene and mail to: MAPS Conferene /o Minnesota Hospital Assoiation 2550 University Ave. W., Ste. 350-S Saint Paul, MN 55114-1900 By fax: (651) 659-1477 Online: visit http://www.mnhospitals.org, lik on Calendar of Events and login to register. 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) 641-1121 prior to the event. Aommodations To make reservations, please all the Marriott Northwest diretly at (800) 441-6422 or (763) 536-8300. Please indiate that you are attending the MAPS Conferene when making overnight aommodations. Room rate: $139 standard suite. Cut-off date: Ot. 5, 2016. 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 12.7 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: 6.4; Day Two: 6.3). Pharmaists: 10.5 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: 5.25; Day Two: 5.25). Long-Term Care Administrators: 10.5 Continuing Eduation Units have been applied for through the Minnesota Board of Examiners for Nursing Home Administrators. (Day One: 5.25; Day Two: 5.25). Registration Fee (Does not inlude lodging aommodations) Before Sept. 11, 2016 $310 MAPS members $360 Non-members $75 Patient or Resident Volunteer Advisors per day After Sept. 11, 2016 $395 All attendees $75 Patient or Resident Volunteer Advisors per day On-site $500 All attendees 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

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Minnesota Alliane for Patient Safety 2016 Conferene Partnering for Safer Care Name: Title: Faility/Organization: Address: City: State: ZIP: Phone: Fax: Email: Please indiate whih breakout sessions you will be attending (hek one per time slot) Thursday, Ot. 27, 2016 11:10 a.m. 12:10 p.m. #1 The New Diagnosti Team Dotors, NPs, PAs, Nurses and THE PATIENT #11 Strengthening Community Partnerships: Post- Disharge Firefighter Visits #2 Lessons Learned from a Traumati Event #12 Improving Provider/Patient Relationships and Diagnosti Quality Through Deliberative Patient Engagement #3 Patient-Instigated Parkinson s Mediation Improvement Projet: A Suess Story Friday, Ot. 28, 2016 11:15 a.m. 12:15 p.m. #4 Transending Burnout: SurTHRIVING in Changing Times #13 Using Clinial and Cultural Change Interventions to Redue CAUTI Thursday, Ot. 27, 2016 1:15 2:15 p.m. #14 Respeting Ourselves and Our Patients: Improving Patient Safety by Improved Handling of Violent Patients #5 Promoting Health Through Happiness Community Resilieny #15 Exploring Patient and Family Engagement Aross Minnesota #6 Moving Patient Safety Forward through Measurement #16 Designing for Mediation Safety #7 When EHRs Cause Patient Harm: Lessons from Malpratie Friday, Ot. 28, 2016 1:15 2:15 p.m. #8 Embrae Your Googling Patients #17 Using LEAN A3 Problem-Solving as a Proative Proess to Improve Patient Safety Friday, Ot. 28, 2016 10 11 a.m. #18 Living Safely in the Community: Children and Adults with Mental Illness #9 Teaming Up to Prevent Biologial Speimen Handling Errors #19 Addressing the Opioid Crisis through Evidene- Based Pain Assessment and Management #10 Evidene-Based Care Delivery: Development and Diffusion of Systemwide Best Praties #20 Partnering with Patients in Strategi Organizational Safety Work 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: 7516