Welcome to the TMIT High Performer Webinar: Chasing Zero Leaders Toolbox: Your Action Pack Hosted by TMIT For resource downloads go to: www.safetyleaders.org 1
Welcome Charles Denham, MD Chairman, TMIT Co-chairman, NQF Safe Practices Consensus Committee Chairman, Leapfrog Safe Practices Program TMIT High Performer Webinar September 23, 2010 2
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Disclosure Statement The following panelists certify: that unless otherwise noted below, each presenter provided full disclosure information, does not intend to discuss an unapproved/investigative use of a commercial product/device, and has no significant financial relationship(s) to disclose. If unapproved uses of products are discussed, presenters are expected to disclose this to participants. Charles Denham: Chairman, TMIT; education grant (CareFusion) and co-production with Discovery Channel Dennis Quaid: has no relevant financial interests in this presentation Steve Rel: has no relevant financial interests in this presentation Susan Sheridan: has no relevant financial interests in this presentation Tom Van Dawark: Employed by Orca Partners, LLC Stephen Swensen: Employed by Mayo Clinic Charlotte Guglielmi: Employed by Beth Israel Deaconess Medical Center Dan Henderson: has no relevant financial interests in this presentation 6
Roundtable Panelists Dennis Quaid* Charles Denham Steve Rel Susan Sheridan* Stephen Swensen* *Pre-recorded Tom Van Dawark 7 Charlotte Guglielmi Dan Henderson
Open: A Call to Action Steve Rel TMIT Patient Safety Advocate Susan E. Sheridan, MIM, MBA* Co-Founder and President, Consumers Advancing Patient Safety; Lead, Consumer Action, World Alliance for Patient Safety, World Health Organization *Pre-recorded TMIT High Performer Webinar September 23, 2010 8
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Chasing Zero and Safe Practice Overview Charles Denham, MD Chairman, TMIT Co-chairman, NQF Safe Practices Consensus Committee Chairman, Leapfrog Safe Practices Program TMIT High Performer Webinar September 23, 2010 10
TMIT Mission Accelerate performance solutions that save lives, save money, and build value in the communities we serve and ventures we undertake. 11
Culture 2010 NQF Report Consent & Disclosure Consent and Disclosure Workforce Information Management and Continuity of Care Medication Management Healthcare-Associated Infections Condition- & Site-Specific Practices 12
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Extraordinary impact through ordinary things Chasing Zero is the first in a series of documentaries produced by TMIT that targets consumers, caregivers, and healthcare leaders. The goal is to inspire them to act now to prevent healthcare harm. The war on healthcare harm is not targeting bad people, but bad systems. These support systems no longer protect caregivers and patients as healthcare has become more complex and fragmented. Healthcare harm has risen from the 8th leading cause of death to the 3rd leading cause of death when we include infections we have given patients during care. 20 jumbo jets are crashing every week in American healthcare The documentary was shot in multiple locations around the world. Interviews of World Health Organization leaders were undertaken in Geneva and London. Dennis Quaid was filmed on the movie set of Soul Surfer on Oahu, Hawaii. Caregivers were shot in action at their hospitals including the Brigham and Women s Hospital, the Mayo Clinic, the Cleveland Clinic, Johns Hopkins, and the Vanderbilt University Medical Center. Zero is the number Now is the time Narrator Dennis Quaid Our goal is to reinforce role models of great caregivers and healthcare leaders, and to open dialogue among governance and leadership teams at America s hospitals and healthcare organizations so our care will be safer and more reliable. DVD Contents and Bonus Features Chasing Zero documentary feature 53-minute run time Medical articles for background reading and continuing education: Chasing Zero: Can Reality Meet the Rhetoric? by Charles Denham, Peter Angood, Donald Berwick, Leah Binder, Carolyn Clancy, Janet Corrigan, and David Hunt The Chasing Zero Department: Making Idealized Design a Reality by Charles Denham, Peter Angood, Donald Berwick, Leah Binder, Carolyn Clancy, Janet Corrigan, and David Hunt Story Power by Dennis Quaid, Julie Thao, and Charles Denham The No Outcome - No Income Tsunami is Here: Are You a Surfer, Swimmer, or Sinker? by Charles Denham Web links to receive free assets, such as the National Quality Forum 2010 Safe Practices for Better Healthcare, in return for survey responses to safe practices adoption. Messages from funding organization leaders. Web links to view other resource materials from Discovery Channel, AORN, CareFusion, TMIT, and other patient safety organizations. Stories of great healthcare leaders and caregiver role models communicate the actions that we can take to save lives, save money, and deliver value to the communities we serve. Visit DiscoveryChannelCME.com Chasing Zero online at www.chasingzeromovie.com Chasing Zero is a trademark of CareFusion Corporation This program was produced with educational grants funding from CareFusion, AORN, and TMIT.
Zero Is the Number Now Is the Time Ground Zero Is the Board Room Dennis Quaid* Actor and Patient Safety Advocate TMIT High Performer Webinar September 23, 2010 *Pre-recorded 20
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It happens one little soul at a time. 22
Five Reasons, Five Ways to Engage Your Board and Utilize Board Member Expertise in Chasing Your Zero Tom Van Dawark, MBA CEO and Principal Consultant, Orca Partners, LLC TMIT High Performer Webinar September 23, 2010 23
Five Reasons to Engage Your Board in Chasing Zero 1. Patient Safety is core to your mission and the crisis 2. 3. 4. 5. is real The Board holds ultimate responsibility for patient safety and quality Significant changes are needed in governance as well as in operational practices The Board must lead, support, and provide the resources for enhancement Board Member expertise, experiences, and unique perspectives will be required 24
Five Ways to Engage Your Board in Chasing Zero 1. Make the case for needed change 2. Make the case for needed Board involvement in change initiatives 3. Include Board Members in your safety improvement work 4. Include Board Members in your routine safety and safety supporting work 5. Ensure your Board routinely sees and is seen by patients and staff 25
High Impact Changes through Simplistic Solutions Stephen Swensen, MD, MMM, FACR* Director for Quality, Mayo Clinic, Rochester TMIT High Performer Webinar September 23, 2010 *Pre-recorded 26
Checklists: Promise, Not Problem Charlotte Guglielmi, BSN, RN, MA, CNOR President, AORN Perioperative Nurse Specialist, Beth Israel Deaconess Medical Center TMIT High Performer Webinar September 23, 2010 27
Checklists Living, evolving instruments Methodical reminders They are not to-do lists Aviation checklists have a critical construction Challenge Verify Response Source: Karl R. Briefings, checklists, geese, and surgical safety. Ann Surg Oncol 2010 Jan;17(1):8-11. 28
Principles of Patient Safety to Be Considered Enhancing communication Building in redundancies & cross cross--checks Standardization Simplification Forcing function Grassroots empowered to lead change 29
Problems or Risk of Checklists Can be misunderstood as rules Some people consider them another to-do list May suggest absence in the application of critical thinking Can result in failure to use open communication Toleration of deviance from checklist among team members could result in patient harm 30
Checklist Basics Applying the Elements Concise Standardized Easily understood by the user Force a function Promote communication Operation of Fire Extinguishers P ull the pin. A im low, at the base of the fire. S queeze the handle. S weep from side to side (Source: Beth Israel Medical Center Employee Comprehensive Education Module) 31
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Check a Box. Save a Life : The Next Generation of Safety Leaders Dan Henderson Medical Student, University of Connecticut School of Medicine; VP of Leadership Development, American Medical Student Association (AMSA) TMIT High Performer Webinar September 23, 2010 34
The Next Generation of Safety Leaders The health student mindset Check a Box... Grassroots 2.0 Sutton s exception A charge, by way of a thanks 35
The mind of a student leader 36
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October 2009 First Wave Impact: Viral Spread to 1,400 38
Spread: Site sign-up over time 39
Sign-up rate by day of campaign 40
Global Reach A Pandemic? 41
Winter-Spring 09-10 Second Wave Impact: Deeper Engagement 42
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2010 and Beyond Lessons and Future Directions 47
Sutton s Exception (go where the money isn t) 48
Sutton s Exception Applied 49
Sutton s Exception Applied 50
A charge, by way of a thanks 51
A charge, by way of a thanks Consider the student mindset. Fit us into the safety equation. Think about the future. 52
Roundtable Q & A Dennis Quaid* Charles Denham Steve Rel Susan Sheridan* Stephen Swensen* Tom Van Dawark Charlotte Guglielmi Dan Henderson *Not part of live Q&A 53
Closing Message Steve Rel TMIT Patient Safety Advocate TMIT High Performer Webinar September 23, 2010 54
Upcoming Webinars October 28 Zero Infections: Getting the Greenlight from Our Leaders November 11 Heparin Accident Prevention: Stop the Bleeding, Start the Leading December 2 Story Power: Don t Be the Last Action Hero! 55