28th Annual National Forum on Quality Improvement in Health Care Sunday, December 4: Registration 7:00 AM - 5:30 PM Pass1 Conference Pass Print Desk
Sunday, December 4: Orientation 11:00 AM - 12:00 PM Orient1 National Forum Orientation (Sunday)
Sunday, December 4: Learning Labs 1:00 PM - 4:30 PM L1 Achieving Equity: Readmissions and Real-World Lessons
Learning Format: Lecture Track: Equity Addressing readmissions while caring for an increasingly diverse population has become a significant concern for hospital leaders. Some minority populations are more likely than white populations to be readmitted within 30 days of discharge for medical conditions such as heart failure, pneumonia, and acute myocardial infarction. This session will provide guidance on how to address the barriers faced by minority populations and focus both system-wide redesign and targeted efforts at preventing readmissions. After this presentation, participants will be able to:
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Provide an overview of the key issues and strategies related to reducing readmissions of racially and ethnically diverse patients
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Identify seven strategies that hospitals can use to reduce readmissions in diverse populations
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Discuss a successful case study that incorporates these seven strategies
Presenters: Betancourt, J., MD, MPH, Director, The Disparities Solutions Center, Massachusetts General Hospital; Tan-Mcgrory, A., MBA, MSPH, Deputy Director, Massachusetts General Hospital L2 Internationally Heralded Approaches to Population Health driven by Alaska Native/American Indian/Native American Communities
Learning Format: Buzz Session Track: Equity Learn from the nationally and internationally heralded models of the SCF Nuka System of Care (Alaska) and the ECHO Program (New Mexico). Both programs are being looked to as models to apply in primary care and community settings to improve outcomes, cost, experience, and expertise for both those giving and receiving services. Both include community driven design, team based expertise, community based structures, workforce innovations, technology optimization, and reach across thousands of miles. After this presentation, participants will be able to:
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Develop an approach to working with communities experiencing equity gaps through a strength-based approach in partnership with people with lived experience
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Identify opportunities to partner in culturally competent ways to address population and community needs
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Identify opportunities to leverage technology to close equity gaps in access while creating workforce innovations that strengthen a community
Presenters: Bird, M., Public Health Consultant, No Organization; Eby, D., MD MPH, Vice President of Medical Services, Southcentral Foundation; Armistad, A., MA, Program Manager, University of New Mexico Health Sciences Center L3 Back to the Basics: Building Essential Quality Improvement Skills
Learning Format: Lecture Track: Improvement Capability Can you run multiple PDSA tests in one day? Do you know when a change concept is ready for implementation, and then sustain the improvements? This session will provide a refresher for those who are stalled and a jump-start for those who are new to the QI journey. Built around the IHI Model for Improvement, this session will demonstrate linkages between aim, measurement, and change concepts and also provide an overview of key tools and methods related to successful improvement initiatives. After this presentation, participants will be able to:
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Provide an overview of the IHI Model for Improvement
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Specify the differences between QI testing, implementing, and spreading
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Identify key concepts and tools that should be part of their QI toolkit
Presenters: Lloyd, R., PhD, Vice President, Institute for Healthcare Improvement; Taylor, J., EdD, Improvement Advisor; Learning Designer, Jane Taylor L4 Creating Adoptable and Sustainable Improvement
Learning Format: Simulation Encounter Track: Improvement Capability In an effort to improve health care, are we making it harder to deliver care? The many QI initiatives that add workload and are not perceived as valuable by care providers can lead to increased burden, workarounds, error, and resistance. In this session, participants will use a case study, simulated exercise, and role-play to understand the factors that lead to sustained improvement and learn about tools to design more easily adoptable improvement strategies. After this presentation, participants will be able to:
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Analyze why some QI strategies lead to more sustained improvement
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Utilize tools to develop more sustainably adoptable improvement strategies
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Use exercises learned in this session to engage others in their organization in initiatives to create sustainable improvement
Presenters: Hayes, C., MD, MSc, MEd, Medical Director, Quality & Performance, St. Michael's Hospital; Federico, F., RPh, Vice President, Senior Expert Patient Safety, Institute for Healthcare Improvement
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28th Annual National Forum on Quality Improvement in Health Care L5 High-Five People at the Center of Quality Improvement
Learning Format: Buzz Session Track: Improvement Capability Person-centered health care is as much about the multidisciplinary teams as it is about the public we serve. This interactive session will share examples of the five key essentials that drive all QI efforts, beginning with the people at the center: patients, families, the self, and the team. It will explore the context of the work, ways to make change happen (beginning with yourself), and methods, tools, and techniques for getting results. After this presentation, participants will be able to:
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Discuss and exchange ideas that build on the five key essentials that drive all QI efforts
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Make a plan to test the five key essentials in their own QI programs
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Make new connections with two other quality improver attendees to share progress using new highfive ideas
Presenters: O'Connor, P., PhD, Director of Care Quality and Strategic Development, Scottish Ambulance Service; Lachman, P., MD, MPH, FRCPCH, CEO, International Society for Quality in Health Care (ISQUA) L6 It Takes a Village to Combat the Opioid Epidemic
Learning Format: Rapid-Fire Sessions Track: Improvement Capability This dynamic discussion will highlight four best practices to combat the opioid epidemic: (1) promoting networking within local coalitions of doctors, community members, and law enforcement to share visions and priorities; (2) organizing a comprehensive plan to reduce over-prescribing across a large integrated health system; (3) leveraging Medicaid health plan resources to lower over-prescribing across a diverse rural region; and (4) as promoted by the CDC, anchoring clinical change in evidence and supporting multi-pronged implementation strategies. After this presentation, participants will be able to:
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Implement proven "best practices" to reduce opioid over-prescribing
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Identify key stakeholders and leaders to build a community coalition to address the opioid epidemic
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Identify strategic actions and interventions by health systems that would reduce opioid overprescribing
Presenters: Moore, R., MD, MPH, Chief Medical Officer, Partnership Health Plan Of California; Hyatt, J., MD, Emeritus Assistant Medical Director, Community Health Initia, Kaiser Permanente; Losby, J., Team Lead, Centers for Disease Control and Prevention (CDC); Pfeifer, K., Director, High Value Care, California HealthCare Foundation
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28th Annual National Forum on Quality Improvement in Health Care L7 Rapid-Cycle Evaluation for Improvement Leaders
Learning Format: Buzz Session Track: Health Plans & Insurers Advancing Improv, Improvement Capability It is crucial that health system leaders and researchers applying improvement initiatives also evaluate and share what they have learned. Improvement initiatives are often complex and evolve as the work unfolds, making evaluation approaches complex. This session will use a mix of presentations and attendee participation to explore a rapid-cycle evaluation approach to learning from improvement initiatives. Participants will have the opportunity to design their own evaluation plan. After this presentation, participants will be able to:
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Identify the evaluation approaches most suitable for their improvement initiatives
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Describe the data that an evaluator can collect to understand progress and learning throughout an initiative
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Develop an evaluation outline for their quality improvement initiative
Presenters: Parry, G., PhD, Senior Scientist, Institute for Healthcare Improvement; Reid, A., MPH, Director, Institute for Healthcare Improvement; Dasgupta, A., Research Associate, Institute for Healthcare Improvement; Goldmann, D., MD, Chief Medical and Scientific Officer, Institute for Healthcare Improvement L8 Start with the Experience: Not Your Average Innovation Workshop
Learning Format: Flipped Classroom Track: Improvement Capability This human-centered design workshop will help health care innovation teams get comfortable with being uncomfortable. We will provide a sneak peek at Providence innovation tools focused on building experiences that meaningfully connect to end-users. Through hands-on exercises, participants will learn approaches to creating new products and services targeted to a health care marketplace that is increasingly consumerdriven and digital. Activities include building inspirational consumer profiles, designing user experience blueprints, and generating new service concepts. After this presentation, participants will be able to:
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Implement a design thinking methodology that creates meaningful experiences with lasting Triple Aim value
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Develop skills to connect teams and foster ideation (rapid generation, iteration, and critique methods)
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Inspire collaboration and play in their service design and development process
Presenters: Conner, G., MBA, MS, director business accelerator, Providence Health and Services; Backett, P., Partner, Evolve Collaborative; Butler, C., Partner, Evolve Collaborative
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28th Annual National Forum on Quality Improvement in Health Care L9 Team Coaching for Improvement Capability and Results
Learning Format: Flipped Classroom Track: Improvement Capability Competing interests, demanding patient needs, and changing improvement priorities can make it challenging to develop improvement capability at the front line of care delivery. However, fundamental improvement capability can lead to sustainable improvement results and bring joy back to health care. We will discuss international examples of team coaching and resulting measures of staff and patient satisfaction, process and clinical outcome improvements, and increases in overall improvement capability while exploring roadblocks, challenges, and successes in coaching health care improvement teams. After this presentation, participants will be able to:
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Describe improvement efforts and capability experiences and challenges in daily care delivery
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Compare and describe each phase of a team coaching model used to increase improvement capabilities in various contexts around the world
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List three roadblocks encountered by team coaching improvement teams and possible strategies to address them
Presenters: Godfrey, M., PhD, MS, BSN, FAAN, Co-Director, The Microsystem Academy Instructor, The Dartmouth Institute; Hvitfeldt Forsberg, H., MSc, PhD student, Karolinska Institute; Geary, U., MBBCh BAO, FRCPI, FRCSEd, FCEM, Consultant in Emergency Medicine, St. James's Hospital; Fristedt, S., n/a, No Organization L10 IHI’s Joy in Work Framework: The Antidote to Burnout
Learning Format: To Be Determined Track: Joy in Work Innovative approaches are urgently needed to help caregivers in office and community settings restore and maintain joy in their work and the work of their staffs. In this session, we will present principles and techniques that enable a workforce to truly thrive, not just persevere, using proven methods to foster a positive work environment that creates equity, camaraderie, meaning, and choice and ensures the commitment to deliver high-quality care, even in stressful times. After this presentation, participants will be able to:
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Describe key leadership behaviors that increase staff engagement and restore joy
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Identify the key changes needed in a system to foster joy in work
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Develop and plan at least one intervention to ensure that the staff at their own organization have a sense of meaning, choice, camaraderie, and equity in their work
Presenters: Swensen, S., MD, MMM, FACR, Medical Director, Leadership & Organization Development, Mayo Clinic; Perlo, J., MPH, Network Director, IHI Open School, Institute for Healthcare Improvement; Lenoci-Edwards, J., RN, MPH, Safety Focus Area Owner, Institute for Healthcare Improvement; Kabcenell, A., RN, MPH, Vice President, Institute for Healthcare Improvement; Kellet, M., Director of Healthcare Strategy, Scottish Government
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28th Annual National Forum on Quality Improvement in Health Care L11 Professionalism and Peer Support: Drivers of Wellness
Learning Format: Case Study Track: Joy in Work The well-being and engagement of our workforces are at risk. Two frequently neglected factors that can support well-being are professionalism and peer support. Respectful professional relationships enhance teamwork and engagement, and peer support after errors and other stressful events is crucial to building a trusting culture. This session will explore opportunities to create a supportive work environment by building programs in professionalism and peer support. After this presentation, participants will be able to:
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Recognize the connections between professionalism, team communication, and well-being
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Identify the emotional impact of adverse events on clinicians
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Explain the rationale for having professionalism and peer support programs
Presenters: Shapiro, J., MD, FACS, Director, Center for Professionalism & Peer Support, Brigham and Women's Hospital L12 Unleashing Everyone as Change Agents for Joy, Health, and Well-being
Learning Format: Flipped Classroom Track: Joy in Work How do we unlock intrinsic motivations and unleash collective joy while swimming in the soup of a complex system? Bring your challenges, experiences, and insights to this un-conference session as together we uncover opportunities for lasting change for joy and meaning. Building on organizational change and social movement practices, participants will leave with practical next steps to jump-start a groundswell of leadership that enables a relationship-centered, joyful environment. After this presentation, participants will be able to:
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Unlock intrinsic motivations by exploring the attributes of their "most joyful day" at work
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Develop a new paradigm for building relationships around shared values
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Discuss organizational change and social movement practices to build a groundswell of leadership for joy in their organizations and communities as well as next steps to build their "joy" muscle at home
Presenters: Hilton, K., JD, MTS, Senior Faculty, ReThink Health; Hartung, H., Consultant Respiratory Physician, National Health Service Ayrshire and Arran; McPherson, M., PhD, MS, Director, 100 Million Healthier Lives Implementation, Institute for Healthcare Improvement L13 Designing for Improved Maternal and Neonatal Health
Learning Format: Lecture Track: Patient Safety Globally a perfect storm is gathering that could improve maternal and neonatal health. This session will present three US initiatives to achieve system-level improvement, followed by a panel and audience discussion in which each project’s design factors will be shared. Focus areas will include physician engagement, innovative tools for learning, structure, and process elements that reduce variation, including the innovative use of simulation techniques and the use of measurement to drive results. After this presentation, participants will be able to:
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Describe three common design elements of the initiatives presented
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Identify key stakeholders who should be involved in improving the health of mothers and neonates at the health-care-system level
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Discuss how they would operationalize this learning to improve the health of their own maternal populations with at least one identified next step to share
Presenters: Leavitt Gullo, S., RN, BSN, MS, Director, Institute for Healthcare Improvement; Deckers, E., Medical Director, Labor and Delivery and Postpartum Services, Hartford HealthCare; Sims, K., Regional Director for Women & Infants, Hartford HealthCare; Bamel, D., MPH, Project Manager, Institute for Healthcare Improvement; Bell, A., RNC, MSN, NEA-BC, CPHQ, Outcomes Specialist, Carolinas HealthCare System; Feldman, D., Physician, Hartford HealthCare L14 Discover the #1 Hidden Harm in Your Hospital
Learning Format: Flipped Classroom Track: Patient Safety Are you ready to boldly look beyond reportable patient harm? Only the courageous need apply! This flipped classroom design will provide compelling new evidence of the national incidence and significance of NonVentilator Hospital-Acquired Pneumonia (NV-HAP). After exploring the facts about NV-HAP, participants will work in small groups to design a practical take-home plan to address NV-HAP in their own hospitals. After this presentation, participants will be able to:
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Describe the significance of NV-HAP at their hospital, including incidence, mortality, length of stay, 30day readmissions, and cost
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Explain new evidence in pathophysiology and prevention of NV-HAP and why all hospital patients are at risk
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Design an implementation blueprint to prevent NV-HAP, including a return on investment analysis, a gap analysis, and specific interventions
Presenters: Baker, D., PhD, APRN-BC, Professor, California State University, Sacramento; Quinn, B., RN, CNS, RN, CNS, Sutter Medical Center L15 Sustainability: Who Has the Answer?
Learning Format: Case Study Track: Patient Safety Why do some solutions to challenging patient safety problems stick and others drift away over time? Through the use of case studies, participants in this session will discuss strategies to increase sustainability, the key factors in success and failure, and known traps. Participants are encouraged to bring current change packages to the discussion. After this presentation, participants will be able to:
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Assess current strategies for program execution aimed at increasing the likelihood of the greatest success in long-term sustainability
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Describe steps taken to build long-term habits of sustainable patient safety initiatives
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Diagnose current approaches to change packages that have resulted in erosion of patient safety efforts over time
Presenters: Chase, A., BS, MS, Consultant, LLC, No Organization; Kotagal, U., MBBS, MSc, Senior Executive Leader, Population and Community Health, Cincinnati Children's Hospital Medical Center; Lilja, B., MD, Chief Medical Officer, Zealand University Hospital
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28th Annual National Forum on Quality Improvement in Health Care L16 Turning Big Ideas into Reality: Large-Scale PDSAs Accelerate National Safety Improvements
Learning Format: Case Study Track: Patient Safety The Solutions for Patient Safety (SPS) network has linked 110 children's hospitals into a learning collaborative to dramatically reduce serious harm to hospitalized children across North America. We viewed every day as a Plan-Do-Study-Act (PDSA) to learn how to effectively use transparency, distributed leadership, family partnerships, large-scale analytics, and cultural strategies in a collaborative model. In this session, we will share learnings that can be applied to other large and audacious improvement efforts in safety and beyond. After this presentation, participants will be able to:
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Identify the key drivers of development of a successful learning network
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Implement these key drivers in developing their own learning network
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Understand how hospitals have overcome key barriers to culture change across hospitals
Presenters: Muething, S., MD, Vice President for Safety, Cincinnati Children's Hospital Medical Center; Lyren, A., MD, Strategic Advisor, Quality & Patient Safety, Rainbow Babies and Childrens Hospital L17 You Can Kick-Start Your Hand Hygiene Program
Learning Format: Simulation Encounter Track: Patient Safety Creating sustainable change in hand-washing practices in the busy health care environment is challenging. This workshop will provide you with tools to engage the partners in your facility, from frontline staff to the Csuite. Methods will vary from simple demonstrations for teaching to robust methodology for sampling that can be tied to infection rates. The team will highlight how their journey captured ongoing momentum from all levels and produced data now owned by all organization members. After this presentation, participants will be able to:
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Identify two key partners in successful, sustainable hand-washing programs
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Design a measurement system for hand hygiene observations that provides randomized sampling in their setting
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Practice two strategies that can be part of a successful hand hygiene program
Presenters: Pfaff, B., Administrative Director, Gundersen Health System; Masterson, C., Infection Preventionist, Gundersen Health System; Dettmering, C., RN, BSN, Quality Improvement Specialist, Gundersen Health System; Fleis, J., BSN, Quality Improvement RN, Gundersen Health System; Oneill, M., Executive Director, Gundersen Health System L18 Caregivers 2.0: You Heard the Stories. Now What?
Learning Format: Buzz Session Track: Person- and Family-Centered Care During this interactive learning lab, the stories of patients and caregivers will provide applicable examples of authentic partnerships between patients, caregivers, and clinicians. Through small-group dialogue, participants will gain insights into the needs and priorities of caregivers during the hardest days of their lives. This workshop will develop ways for participants to engage caregivers in a true partnership for the care of patients and help them understand what really matters to caregivers. After this presentation, participants will be able to:
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Describe how to coordinate the experience of patients and caregivers with the expertise of the health care team for better outcomes
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Understand the role of the caregiver as a resource to the care team
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Identify strategies for engaging caregivers as part of the care team
Presenters: Bartel, R., Patient advocate, No Organization; Mullen, C., Doctoral Candidate/Associate Instructor, Indiana University Purdue University Indianapolis; Hoy, S., Director, Strategy and Development, Patient & Family Centered Care Partners; Bartel, D., Patient Caregiver, No Organization L19 Patient and Family Engagement in Office Practice
Learning Format: Buzz Session Track: Patient Safety In a co-production model, information and decisions are shared between providers and patients to ensure optimal outcomes. In this session, participants will learn about the concepts underlying co-production in health care and explore opportunities to use this method in health care transformation that emphasizes partnership with patients and families to produce safer and higher-value care. Small-group activities will help identify new change packages, examples of advanced practices, and strategies for implementation in office practice. After this presentation, participants will be able to:
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Understand the basic principles of co-production in health care
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Discuss co-production tools and strategies and demonstrate their application in patient and family engagement scenarios
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Develop an action plan to address opportunities in their own organization to use a co-production model to effectively engage patients and families
Presenters: Bristol, T., MA, Director of Patient and Family Engagement, University of North Carolina (UNC) at Chapel Hill; Haskell, H., MA, President, Mothers Against Medical Error; Hatlie, M., CEO, Project Patient Care; Smith, K., PhD, Director, MedStar Health L20 Continuous Value Improvement: Beyond Episodic Gains
Learning Format: Simulation Encounter Track: Quality Cost and Value Lean Accounting has been used to great benefit in many industries for more than 15 years. This simple and timely method for managing cost and value provides frontline managers with weekly information that enables them to control and improve financial results and monitor quality by quickly identifying improvement opportunities, understanding the real bottom-line impact of their decisions, and maximizing benefits to patients and staff. Participants in this learning lab will learn applications of Lean Accounting in health care. After this presentation, participants will be able to:
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Discuss the principles of Lean Accounting and its application to health care delivery
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Illustrate Lean Accounting "in action" using a case study
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Identify two to three opportunities to introduce Lean Accounting tools and concepts in their own work
Presenters: Little, K., Ph.D, Principal, Informing Ecological Design, LLC; Mate, K., MD, Chief Innovation & Education Officer, Institute for Healthcare Improvement; Maskell, B., BSc Honors, Business Consultant, BMA Inc.; Rakover, J., Research Associate, Institute for Healthcare Improvement
Created Date : 9/22/2016
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28th Annual National Forum on Quality Improvement in Health Care L21 Designing High-Impact Value Improvement Projects
Learning Format: Buzz Session Track: Quality Cost and Value In this buzz session learning lab, participants will work collaboratively with interprofessional teams to design and critically evaluate pragmatic, high-impact value improvement projects. Our interprofessional team will review best practices for combining clinical insights and c-suite directives based on our book Understanding Value-Based Healthcare (McGraw-Hill). Using a Costs of Care project development template, participants will work collaboratively to develop and pitch their ideas to a panel of experts. After this presentation, participants will be able to:
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Identify and prioritize organizational opportunities to provide better care at lower cost
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Utilize the COST framework to develop interprofessional high-impact value improvement projects
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Design a high-impact value improvement project that could be adapted and sustained in the context of their own organization
Presenters: Shah, N., MD, MPP, Executive Director, Costs of Care; Moriates, C., MD, Assistant Dean of Healthcare Value and Associate Professor, Dell Medical School at the University of Texas at Austin; Arora, V., MD, MAPP, Director GME Clinical Learning Environment Innovation, University of Chicago Medical Center; Wallingford, S., RN, MSN, APRN-BC, Director of Operations, Costs of Care; Harmon, J., Director, Hospital For Special Surgery L22 How to Build an Accountable Post-Acute Network
Learning Format: Case Study Track: Quality Cost and Value Baystate Health, a Next Generation ACO and BPCI participant, created a preferred provider network to improve post-acute quality and cost outcomes. We will share lessons learned in implementing a preferred network, from evaluating post-acute provider performance to guiding patients to high-quality providers at the point of discharge. Baystate Health’s post-acute strategy has been integral to its success under new payment models. A step-by-step guide will be provided. After this presentation, participants will be able to:
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Organize potential narrow network facilities from a field of providers
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Create a tool to quantitatively and qualitatively select a narrow network for a post-acute facility and rank selected facilities transparently to motivate both selected and nonselected providers
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Establish a partnership to continuously monitor readmissions and length-of-stay outcomes as a Next Generation ACO
Presenters: McQueeney, M., MPH DNP, President Baystate VNA and Post Acute Executive, Baystate Health; Hu, L., MD, MBA, Co-founder & CEO, CarePort Health
Created Date : 9/22/2016
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28th Annual National Forum on Quality Improvement in Health Care L23 Overwhelmed by the Baldrige Criteria’s 256 “How” Questions? 30 Key Systems for High Performance
Learning Format: Case Study Track: Quality Cost and Value Do you struggle with creating reliable systems that improve quality and engagement while decreasing cost? This learning lab will demonstrate how the CAMC Health System, a 2015 Malcolm Baldrige National Quality Award recipient, used the Baldrige Performance Excellence Framework to develop 30 key systems that provide the framework for delivering top-decile care. Participants will learn about these systems and how they can be applied to their workplace and will apply learnings to common workplace problems. After this presentation, participants will be able to:
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Utilize the Baldrige Performance Excellence Framework to develop a systems approach for high performance
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Understand how CAMC identified and developed 30 key systems throughout the organization and engaged the entire workforce in improvement
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Apply the learnings to their own workplace
Presenters: Crotty, G., MD, COO, EXC VP, Charleston Area Medical Center; Grant, B., BSN, MBA, Chief Strategy Officer, Charleston Area Medical Center L24 A Values-Based Approach to Accountable Care
Learning Format: To Be Determined Track: Health Plans & Insurers Advancing Improv, Triple Aim for Populations The HHS goal of tying 50% of fee-for-service payments to ACOs and other values-based payment models by 2018 sends a clear signal that we are moving away from the economically unsustainable FFS-driven environment and toward more cost-effective care that better meets the needs of patients and populations. During this interactive session, a diverse group of ACO leaders will share their successes and challenges in leading health system transformation, and participants will share with and learn from one another. After this presentation, participants will be able to:
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Identify common challenges and solutions to running a successful ACO
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Discover opportunities to accelerate their own efforts to achieve cost- and quality-related improvements at scale
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Engage in active peer sharing and learning
Presenters: Loehrer, S., MD, MPH, Head of North America Region, Institute for Healthcare Improvement; Kerwin, G., FACHE, President and Chief Executive Officer, Bellin Health; Benjamin, E., MD, Senior Vice President for Quality and Pop Health, Baystate Health
Created Date : 9/22/2016
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28th Annual National Forum on Quality Improvement in Health Care L25 Behavioral Health and Primary Care Integration: Payer-Led Practice Transformation
Learning Format: Case Study Track: Health Plans & Insurers Advancing Improv, Triple Aim for Populations “Whole person care” is not just a buzz word: studies show that integrated medical/behavioral health care leads to better patient outcomes and experiences and lower costs. This interactive session will highlight the work of three innovative health plans leading practice transformation initiatives. Participants will learn from key stakeholders about essential elements of the process, including the need for a sense of adventure and humility, the application of QI methodology to integrating care teams, and development of alternative payment models to support the new work. After this presentation, participants will be able to:
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Understand the impact of integrated behavioral health and primary care on health outcomes, patient and provider satisfaction, and costs of care
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Describe the different ways in which three innovative payers have supported the integration of behavioral health and primary care and the tangible process change elements needed (and the landmines to avoid) in implementing an integrated behavioral health model
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Define key strategies to engage payers and providers in their own communities to move toward sustainable models of integrated care
Presenters: Laderman, M., MSPH, Senior Research Associate, Institute for Healthcare Improvement; Lindsey-Pengelly, L., PhD, MSCP, Executive Director, HealthThink; Stadtlander, M., MPH, Executive Director of Network and Clinical Services, CareOregon; Anderson, M., Chief of Medical Services, Inland Empire Health Plan; Huff, A., Behavioral Health Innovation Specialist, CareOregon L26 Improving Outcomes for High-Needs, High-Costs Individuals: What Help Is Available?
Learning Format: Case Study Track: Health Plans & Insurers Advancing Improv, Triple Aim for Populations In this interactive session, participants will learn a well-tested way to design effective programs for complex patients, based on exemplars from Care Oregon, Stanford Coordinated Care, and Cambridge Health Alliance. The best knowledge from the literature, the field, and available resources will provide invaluable context for participants as they navigate the redesign process. After this presentation, participants will be able to:
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Discuss what is known about what works for the care management of individuals with high needs and high costs
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Describe a tested process for redesigning care programs for high-needs, high-costs individuals
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Identify the resources available to support the work of redesigning care for high-needs, high-costs individuals
Presenters: Sevin, C., RN, MSN, NP, Director, Institute for Healthcare Improvement; McCarthy, D., MBA, Senior Research Director, Commonwealth Fund; Ramsay, R., BSN, MPH, Director - Population Health, CareOregon; Glaseroff, A., MD, Co-Founder, Stanford Coordinated Care, Stanford Hospital and Clinics; Carr, E., MBA, LICSW, Senior Director, Care Integration, Cambridge Health Alliance
Created Date : 9/22/2016
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28th Annual National Forum on Quality Improvement in Health Care L27 More Than Medical: The Impact of Social Determinants of Health on Utilization Risk
Learning Format: Case Study Track: Equity, Triple Aim for Populations Current risk assessment methods often overlook social determinants of health, such as homelessness or past trauma, that could be used to predict risk for hospital utilization. In this collaborative learning session, presenters from CareOregon and Community Care of North Carolina will offer ways to identify and target these factors to support comprehensive care for the patient and reduce hospital cost and utilization, as well as guide participants through data analysis, risk modeling, and applications to case studies. After this presentation, participants will be able to:
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Analyze the implications of social determinants of health for patient risk profiles and health care costs and utilization
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Differentiate between impactable and non-impactable patients and develop strategies to target risk factors
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Develop sustainable, multidisciplinary strategies to target complex risk at the population and individual levels
Presenters: Jackson, C., Director of Program Evaluation, Community Care of North Carolina; Duck, J., R.N., B.S.N., High Risk Populations Programs Manager, CareOregon; Shaw, E., RN, BSN, Transitional Care RN, CareOregon; Youngs, K., BSN, RN, CHPN, Palliative Care Supervisor, CareOregon L28 Patients Agree: Let Paramedics Treat Me at Home
Learning Format: Flipped Classroom Track: Triple Aim for Populations Would patients prefer to have their acute medical conditions treated at home instead of in the hospital? After receiving 1,100+ community paramedic responses in our Advanced Illness Management Program, our patients have answered with a resounding “yes!” Using a flipped classroom method, this session will engage participants in learning about community paramedicine in an advanced illness management program and explore the model’s tremendous potential, using our recent expansion to hospice as an example. After this presentation, participants will be able to:
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Understand the capacity for paramedics to act as physician extenders to provide timely urgent care in the home
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Catalyze ideas for building community paramedicine programs in other communities
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Apply knowledge gained from this session to a simulated community paramedic response
Presenters: Abrashkin, K., MD, Medical Director-Clinical Call Center; Physician-House Calls, Northwell Health; Washko, J., MBA, NREMT-P, AEMD, Assistant Vice President, Northwell Health; Hinkelman, M., CEO, Hospice Care Network; Attivissimo, L., MD FACP FAAHPM HMDC, Senior Medical Director Hospice Care Network, Northwell Health; Smith, K., MD, Vice President & Medical Director for Advanced Illness Management, Northwell Health
Created Date : 9/22/2016
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28th Annual National Forum on Quality Improvement in Health Care L29 Primary Care Transformation in the Era of Value
Learning Format: Buzz Session Track: Health Plans & Insurers Advancing Improv, Triple Aim for Populations The stakes for primary care have never been higher. As practices move into alternative payment models under MACRA, they must fundamentally change how they deliver care, partner with payers, and use data to drive improvement. In a value-based era, how can we avoid confusing and overwhelming clinicians while improving transparency and quality? Building on lessons from the Comprehensive Primary Care (CPC) initiative and opportunities in the new CPC+ model, we will explore strategies to develop these capabilities. After this presentation, participants will be able to:
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Describe specific capabilities that primary care practices need to successful use alternative payment models
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Determine how practices can leverage nonfinancial support from payers, such as regular data feedback
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Identify opportunities to increase their primary care practice's comprehensiveness and meet the majority of their patients' needs
Presenters: Jin, J., MSPH, Social Science Research Analyst, Centers for Medicare and Medicaid Services; Finke, B., MD, Physician, Indian Health Service; Schechter, G., Social Science Research Analyst, CMS Innovation Center L30 Real Population Health: Building Sustainable Communities
Learning Format: Case Study Track: Health Plans & Insurers Advancing Improv, Triple Aim for Populations Can population health be improved using rigorous scientific approaches to quality improvement? Three global leaders of health and health care will present examples to suggest the answer is yes. They will argue that there is no other way to do it and simply improving the health care system is not enough. Organizing and building coalitions and partnerships for second-level social change is instrumental in driving results. This session will seek practical answers and actions to improve population health. After this presentation, participants will be able to:
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Understand global examples of change applied to broad populations
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Identify key actions and methods for improving population health in their communities
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Plan their first steps in applying quality improvement techniques to their population health challenges
Presenters: Leitch, J., National Clinical Director, Scottish Government Health Department; Henriks, G., Chief Executive of Learning and Innovation, Qulturum; Knox, P., MS, BS, Executive Vice President, Chief Learning and Innovation Office, Bellin Health
Sunday, December 4: Receptions and Meals 5:00 PM - 7:00 PM Intlmtg International Attendee Meeting
Monday, December 5: Registration 6:30 AM - 5:30 PM Pass2 Conference Pass Print Desk Created Date : 9/22/2016
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28th Annual National Forum on Quality Improvement in Health Care Monday, December 5: Orientation 7:00 AM - 8:00 AM Orient2 National Forum Orientation (Monday)
Monday, December 5: Excursions 8:00 AM - 5:00 PM FE1 Central Florida Zoo: Patient Care and Operations
Learning Format: Simulation Encounter This Excursion will go "backstage" at the Central Florida Zoo, a large-scale operation engaged in the care of very special "patients." Participants will learn key efficient safety processes in the zoo's strategy for providing care for more than 400 animals. Participants will also learn key concepts from this non-health-care setting that can be applied to staff and patients in their own work environments. After this presentation, participants will be able to:
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Identify ways of managing large-scale operations and patient care from a non-health-care industry
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Develop ideas for improving organization-wide operations and patient care processes in their own work environment
Presenters: DeBartolo, K., National Field Manager, Institute for Healthcare Improvement; Duncan, K., RN, Faculty, Institute for Healthcare Improvement FE2 Gaylord Palms Resort: Joy in Work and Customer Satisfaction
Learning Format: Simulation Encounter This Excursion will give participants an opportunity to learn how Gaylord Palms, a large hotel and convention center, improved its operating margin, increased customer satisfaction, enhanced workforce morale, and reduced employee attrition by focusing on employee satisfaction and joy in work. Participants will learn how the strategies employed by this non-health-care organization could be applied in the health care environment. After this presentation, participants will be able to:
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Identify joy-in-work and staff retention strategies in a non-health-care industry that can be compared with, and applied to, their own work environments
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Recognize and analyze key concepts of employee motivation and staff engagement in different industries
Presenters: Gunther-Murphy, C., Executive Director, Institute for Healthcare Improvement; Dickson, E., MHCM, MD, President and CEO UMass Memorial Health Care, University of Massachusetts Memorial Medical Center
Created Date : 9/22/2016
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28th Annual National Forum on Quality Improvement in Health Care FE3 Universal Orlando®: Safety and Reliability
Learning Format: Simulation Encounter Sword fights … staged gunshots … boat explosions … what do these have in common with patient safety and reliability in health care? Learn how the Universal Orlando stunt team ensures the safety of staff and visitors during high-risk stunts, addresses reliability during handoffs and staffing changes, and handles unexpected events. After this presentation, participants will be able to:
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Recognize and analyze key concepts of safety and reliability in various settings
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Develop ideas for improving safety in their own work environments
Presenters: Griffin, F., RRT, MPA, Owner, Fran Griffin & Associates LLC; Lachman, P., MD, MPH, FRCPCH, CEO, International Society for Quality in Health Care (ISQUA) FE4 Orlando Health System Site Visit: Delivering Great Care with High Reliability
Learning Format: Simulation Encounter Get a behind-the-scenes look at how Orlando Health System has fostered the deep engagement of its clinicians, staff, and patients through a focus on teamwork and results. Participants in this hospital site visit will get an opportunity to visit the largest neonatal intensive care unit (NICU) in the world and learn how Orlando Health System delivers great, person-centered care with high reliability. After this presentation, participants will be able to:
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Describe the structures that build the deep engagement of clinicians and staff
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Discuss the leadership behaviors that can deepen the engagement of staff and patients and lead to great results
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Develop two strategies to improve engagement at their institutions
Presenters: Baehrend, J., MA, IHI Fellowship Director, Institute for Healthcare Improvement FE5 Marriott World Center: Managing Large-Scale Operations
Learning Format: Simulation Encounter In this Excursion, participants will learn how the Marriott World Center handles the flow of large volumes of visitors yet offers superb customer service in the front office, adheres to schedules in the banquet kitchen, runs a golf club, tends to every detail of event and convention services, and manages daily housekeeping operations. After this presentation, participants will be able to:
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Recognize and analyze key concepts of operations and flow in different industries
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Develop ideas for improving flow in their own work environments
Presenters: Schall, M., MA, Senior Director, Institute for Healthcare Improvement
Monday, December 5: Minicourse
Created Date : 9/22/2016
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28th Annual National Forum on Quality Improvement in Health Care 8:30 AM - 4:00 PM M1 Achieving Health Equity: What Will It Take?
Learning Format: Buzz Session Track: Equity Martin Luther King Jr. said, “Of all the forms of inequality, injustice in health care is the most shocking and inhumane.” The time is past due to address the moral imperative and practical necessity of the IOM aim of equity. This session will detail diverse and innovative approaches to increasing equity and provide case examples and lessons learned. IHI Fellows will coach participants in developing an achievable plan to bring back to their organization. After this presentation, participants will be able to:
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Identify strategies for building the will in their organization to achieve greater equity
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Apply tools for health equity improvement, including measurement frameworks, policy frameworks, and improvement methods
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Develop an action plan for next steps
Presenters: Botwinick, L., M.S., Director, Graduate Program in Health Admin & Policy, University Of Chicago; Fleishman, J., PhD, Director, Behavioral Science, Leadership Development, and QI, Tufts Family Medicine Residency at CHA; Berwick, D., MD, MPP, President Emeritus and Senior Fellow, IHI, Institute for Healthcare Improvement; Reid, A., MPH, Director, Institute for Healthcare Improvement; Wyatt, R., MD MHA Merck Fellow IHI 2009-2010, Medical Director, The Joint Commission; Wilson, C., MA, MHS, CPHQ, Health Equity Subject Matter Expert, No Organization M2 Building an Improvement Capability Training Program
Learning Format: To Be Determined Track: Improvement Capability By adapting quality improvement methodologies to fit the language and values of the healing professions, you can build a quality improvement training program that engages your frontline management and senior leadership and teaches them about the benefit of delivering high-quality care while eliminating waste in the system. Participants will learn how to build their own quality-based program to increase care quality, reduce cost, and increase employee engagement. . After this presentation, participants will be able to:
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Understand the value to their organization of starting an improvement capability training program
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Demonstrate how increasing quality lowers the cost of health care delivery in their system through waste reduction
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Discuss what is involved in starting their own improvement capability training program
Presenters: James, B., MD, MStat, Chief Quality Officer, Intermountain Healthcare; Reinertsen, J., MD, President, The Reinertsen Group; Wurtz, J., Clinical QI Education Coordinator, Intermountain Healthcare; Allen, T., MD, FACEP, Assistant Quality Officer, Medical Director EDDT, Intermountain Healthcare
Created Date : 9/22/2016
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28th Annual National Forum on Quality Improvement in Health Care M3 Key Lessons from Improvement Around the World
Learning Format: Rapid-Fire Sessions Do you want to know how to lead improvement work in different contexts? This rapid-fire minicourse will take you on an interactive journey featuring improvement stories from IHI partners working on health and health care around the world. Learn about the core design components of successful improvement initiatives and how these have been modified based on contextual variables. After this session, you will have a framework and tools to help you implement your improvement initiative. After this presentation, participants will be able to:
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Understand the core design components that increase their chances of leading a successful improvement initiative
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Incorporate the core components into their own improvement work
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Describe modifications in improvement projects from around the world and IHI's results-oriented initiatives on different continents
Presenters: Delgado, P., MSc, Executive Director, Institute for Healthcare Improvement; Ali, A., BSc(Hons), MBChB, MRCGP(UK), MBA, Executive Director, Middle East/Asia-Pacific, Institute for Healthcare Improvement; Sodzi-Tettey, F., MD, MPH, Director of Ghana Operations, Institute for Healthcare Improvement M4 Learning to Coach and Coaching to Improve
Learning Format: Buzz Session Track: Improvement Capability High-performing teams usually attribute much of their success to their coach, yet many improvement teams have no coach or facilitator to help achieve goals and build capacity, and they often lose energy and direction as a result. This session will review the essential role and skills of an effective coach, using exercises and coaching scenarios to apply participants' coaching skills to typical team challenges. After this presentation, participants will be able to:
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Describe the critical role of improvement coaches within an organization
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Understand that coaches need to build skills not only in QI methods and tools but more importantly in managing the human side of change
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Identify and practice key coaching skills, such as facilitating effective meetings, using team decisionmaking tools, understanding different working styles, and building effective measurement systems
Presenters: Lloyd, R., PhD, Vice President, Institute for Healthcare Improvement; Virgil, P., MHA, ASQ, CSSBB, Improvement Advisor, PMV Consulting; Baldoza, K., MSW, Executive Director, Institute for Healthcare Improvement
Created Date : 9/22/2016
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28th Annual National Forum on Quality Improvement in Health Care M5 Specialty Practice: Ready for New Payment Models?
Learning Format: Lecture Track: Improvement Capability Patient-centered specialty practice (PCSP) defines how specialty clinics should track and coordinate referrals, improve access and communication, manage population, and measure and improve performance. As a specialist, are you ready for MACRA? Will PCSP help you prepare for MACRA? How will PCSP benefit your practice? What does it take to achieve PCSP? This hands-on tutorial will guide you through the National Committee on Quality Assurance (NCQA) standards for transforming specialty care. After this presentation, participants will be able to:
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Prepare specialty practices for new payment models through practice improvement
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Describe the specific benefits of achieving PCSP
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Show familiarity with the process of leading a project to transform specialty clinics toward PCSP
Presenters: Huang, X., MD, MHCM, FACC, President-elect Medical Staff, Providence Milwaukie Hospital, Providence Health and Services; Jones Larson, L., MHA, FACHE, Director, Clinical Operations, Providence Health and Services; George, L., Project Manager, Portland IPA; Sauer, J., VP - Consulting, Medaxiom; Warhus, D., MD, President, Women's Healthcare Associates; Beatty, S., CMPE, Director of Operations, Women's Healthcare Associates; Langer, L., MD MSHS, Practice President, Compass Oncology; Perrigo, B., Executive Director, Compass Oncology M6 Using Improvement Theory to Listen. Really Listen.
Learning Format: Buzz Session Track: Improvement Capability In his 2015 plenary, Don Berwick summoned us to “recommit to improvement science and to listen—really listen.” We wholeheartedly believe that Deming’s System of Profound Knowledge (SPK) helps us do just that —to “listen” to the voice of our system, of those we serve, and of those who serve. Recommit to improvement science in this session by exploring how Deming’s theories reveal the voices necessary to better understand our complex systems and improve our interactions toward improvement. After this presentation, participants will be able to:
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Share Deming’s SPK as a framework for listening to the voices within their system in support of their improvement work
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Apply components of Deming’s theories to examples and to their own improvement projects
Presenters: Butts-Dion, S., Improvement Advisor, Butts-Dion Consulting, Inc.; Taylor, J., EdD, Improvement Advisor; Learning Designer, Jane Taylor; Crowe, G., RN, EdD, Principal, Hamilton Consulting, LLC
Created Date : 9/22/2016
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28th Annual National Forum on Quality Improvement in Health Care M7 Personal Mastery for Relational Barriers to Change
Learning Format: Case Study Track: Joy in Work High-quality work relationships are key for successful transformation, but the volatility, uncertainty, and complexity inherent in health care make relational barriers very common. At times these stress factors can easily rattle even those with the best relational skills, no matter how experienced they are. This leads to avoidable resistance and interpersonal tensions. Through case examples, participants will learn methods for personal mastery—ways to bring forth their highest relational skills in tough situations. After this presentation, participants will be able to:
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Explain methods for identifying and shifting out of reactions to complexity and stress that get in the way of high-quality work relationships
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Define their personal vision for high-quality work relationships and translate it into specific behaviors for action
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Explain the key elements of dialogue for working through difficult situations
Presenters: Baker, N., MD, Principal, Neil Baker Consulting and Coaching M8 Rock the Boat and Stay In: Being a Great Change Agent
Learning Format: Flipped Classroom Track: Joy in Work As leaders and activists in health care improvement, we need to challenge existing thinking, culture, and practice. Not an easy life! This inspiring and highly active minicourse offers practical methods for surviving and thriving as an agent of change. Participants will learn tools to help make change happen even when others are resistant and will gain perspective on their own resilience as a change agent in order to remain strong, effective, and adaptable in their improvement practice. After this presentation, participants will be able to:
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Discuss the tactics and success strategies of seasoned improvement leaders and increase their own effectiveness as leaders of change
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Reframe their perspective on resilience to change and also increase their ability to adapt to adversity, recover from failure, and see challenges as opportunities
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Take home a toolkit of alternative approaches to supporting change to complement their health care improvement toolkit and make their improvement efforts more likely to succeed
Presenters: Bevan, H., PhD, Chief Transformation Officer, Horizons Team, NHS England; Perera, K., Head of Transformation, NHS England Sustainable Improvement Team
Created Date : 9/22/2016
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28th Annual National Forum on Quality Improvement in Health Care M9 Joy in Work: Four Actions Taken by Effective Leaders
Learning Format: Case Study Track: Leadership Do you wonder how to create joy in work while achieving other vital health care outcomes? Are you confused by separate lists of leadership behaviors required for the Triple Aim, for joy in work, etc.? With clarity on essential behaviors, you can cut through the noise of competing lists and put ideas into action. This session will provide four leadership actions and a roadmap to create a sense of joy in work, reduce burnout, and achieve Triple Aim outcomes. After this presentation, participants will be able to:
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Describe four evidence-based leadership practices that increase joy in work and decrease burnout
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Develop leadership practices to rapidly improve joy in work, quality, safety, and experience outcomes
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Design and construct an organizational roadmap to increase joy in work
Presenters: Balik, B., RN, EdD, Co-Founder, Aefina Partners; White, K., RN, BSN, MBA, Co-Founder, Aefina Partners M10 Engaging Physicians to Transform Care
Learning Format: Lecture Track: Leadership Are physicians in your organization taking the lead in improving care or are they reluctant participants sitting on the sidelines? There are no shortcuts to better quality, safety, or value, and active physician engagement is critical. To fully participate, most physicians need to acquire skills in improvement methods and expand traditional views of autonomy, teamwork, leadership, and accountability. This session will present lessons from the Virginia Mason experience and principles in engaging physicians to transform care. After this presentation, participants will be able to:
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Describe how urgency, shared vision, change sponsorship, an explicit compact, and a single organization-wide improvement method facilitate physician engagement
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Articulate how to address the unspoken assumptions that become barriers to physician engagement in improvement
Presenters: Silversin, J., DMD, DrPH, President, Amicus, Inc.; Kaplan, G., MD, Chairman & CEO, Virginia Mason Medical Center M11 High-Impact Leadership in the Real World
Learning Format: Lecture Track: Leadership As health care continues to evolve, what does leadership mean in this world of constant challenge and change? Are there high-impact changes that can accelerate transformation across health and social care? This session will draw on real-life examples of these questions being answered with a resounding "yes." Using IHI's newest thinking on leading improvement and building on recent lessons in navigating change, the speakers will draw on their global experience to describe how to lead sustainable change. After this presentation, participants will be able to:
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Identify their own mental leadership models and key leadership behaviors
Created Date : 9/22/2016
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28th Annual National Forum on Quality Improvement in Health Care •
Develop new individual and organizational leadership skills and behaviors consistent with achieving Triple Aim results
Presenters: Swensen, S., MD, MMM, FACR, Medical Director, Leadership & Organization Development, Mayo Clinic; Feeley, D., President and Chief Executive Officer, Institute for Healthcare Improvement; Leitch, J., National Clinical Director, Scottish Government Health Department M12 High-Impact Leadership: Developing Core Leaders
Learning Format: Case Study Track: Leadership Core leaders are the managers and clinical team leaders “in the middle” who are responsible for the day-today provision of clinical care and support services. They make care happen, yet support for individual leadership and management development is often inadequate. Participants will explore new thinking on the “four jobs” of core leaders and learn practical approaches from Orlando Health, where nursing and allied health have partnered to create a culture of continuous improvement and quality care. After this presentation, participants will be able to:
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Understand in depth the “four jobs” of core leaders
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Apply practical insights to developing their core leaders and teams
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Describe new behaviors critical to the practice of leadership “in the middle”
Presenters: Reed, C., MBA, R.T. (R)(MR), Chief Operating Officer, Orlando Health; DeYoung, A., MBA, RRT, Administrator, Orlando Health; Peach, A., R.N., M.S.N., NEA-BC, Partner, Future Vision Group; Pugh, M., MPH, President, MdP Associates, LLC; Munch, D., MD, SVP Chief Clinical Officer, Healthcare Performance Partners M13 Leading in a Crisis: The Power of Transparency
Learning Format: Flipped Classroom Track: Leadership Serious clinical failures occur in all organizations. How an organization responds to these crises can either seriously harm or strengthen it. A slow, reluctant, defensive response makes a bad situation much worse. Organizations that act promptly, transparently, and empathetically can grow stronger and reduce future risks. Through interactive role-play and case-based discussions, this session will help you lead your organization through crisis to true high performance. After this presentation, participants will be able to:
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Understand some key skills for dealing with the media, legal advisers, patients, and the public transparently and empathetically
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Identify the leadership behaviors that are most likely to begin to rebuild trust in the face of serious clinical failures
Created Date : 9/22/2016
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Describe the key components of crisis management that promote long-term organizational learning, development, and growth
Presenters: Stewart, K., MB MPH FRCP FRCPI, Clinical Director, Clinical Effectiveness Unit, Royal College of Physicians; Sadler, B., JD, Senior Fellow,IHI, Institute for Healthcare Improvement; Oldham, M., Healthcare Management Consultant, No Organization; Snyderman, N., MD, FACS, Faculty, Department of Otolaryngology, University of Pennsylvania M14 Practical Skills in Patient Safety Tools
Learning Format: Lecture Track: Patient Safety We invest significant resources in tools such as RCA and FMEA as approaches to understanding and preventing harm, but their use rarely results in learning or improvement, and the same types of harm reoccur. Taking a fresh look at these tools, we will examine practical ways to make them effective and improvement-focused by practicing skills in a range of core safety tools and focusing on turning learning into improvement as an effective way to prevent harm. After this presentation, participants will be able to:
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Develop practical skills with a range of safety tools that they can use straightaway
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Drive improvement using learnings from RCAs and FMEAs
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Engage in huddles and walkarounds in a way that has a huge impact in their unit, practice, or team
Presenters: Brooks, A., Client Portfolio Director Patient Safety, Institute for Healthcare Improvement; Haraden, C., PhD, Vice President, Institute for Healthcare Improvement; Lenoci-Edwards, J., RN, MPH, Safety Focus Area Owner, Institute for Healthcare Improvement M15 Reducing Diagnostic Errors: A Practical Workshop
Learning Format: Buzz Session Track: Patient Safety Diagnostic errors represent the next frontier of patient safety. This workshop will present a comprehensive approach to improving diagnostic reliability that can be made part of existing patient safety programs. Participants will engage in practical exercises addressing measurement, analysis, and cognitive and systems causes of diagnostic errors. An array of potential solutions will be discussed, and participants will take home tools and strategies for improving diagnostic reliability. After this presentation, participants will be able to:
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Describe how cognitive biases contribute to diagnostic error and discuss the epidemiology of diagnostic error
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Apply a specific tool to analyze diagnostic errors
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Identify methods to minimize errors in diagnosis in the clinical setting
Presenters: Salvador, D., MD, MPH, Vice President, Medical Affairs, Baystate Medical Center; Trowbridge, R., MD, Division Director, General Internal Medicine, Maine Medical Center; Hoar, H., MD, Med-Peds Hospitalist, Baystate Medical Center
Created Date : 9/22/2016
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28th Annual National Forum on Quality Improvement in Health Care M16 Understanding Patient Harm and Risk: What More Can We Do to Improve?
Learning Format: Flipped Classroom Track: Patient Safety Despite considerable increases in awareness and resources, decreases in patient harm have been slow and variable. This session will review different ways to measure and understand harm and risk and apply harm and risk reduction strategies, drawing lessons from leading organizations and from the exchange among participants. Approaches will include improvement interventions, strategies for culture change, necessary infrastructure, monitoring, and the synergies among these elements. Participants will leave with a plan for their organization. After this presentation, participants will be able to:
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Understand why, despite all the investment, patient safety efforts are not showing results matching their potential
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Describe approaches to understanding harm and risk in their own organization
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Develop their own patient safety improvement plan
Presenters: Federico, F., RPh, Vice President, Senior Expert Patient Safety, Institute for Healthcare Improvement; Staines, A., PhD, Professeur associé, University of Lyon M17 Patient and Family Adviser Summit
Learning Format: Buzz Session Track: Person- and Family-Centered Care The Patient Family Adviser Summit will be an opportunity for Patient Family Advisers to connect, empower, and share skills with one another. It will provide a collaborative space in which to inform and be informed by the national partners driving policy and improvement in patient family engagement practice. Participants will have an interactive day of collaborative learning, facilitated discussion, and action planning to capitalize on mutual commitments to engage Advisers authentically in quality improvement. After this presentation, participants will be able to:
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Discuss specific strategies for integrating Patient Family Advisers into QI work through interactive, peer-supported learning
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Describe the work of national organizations in supporting the engagement of patients and families in health care improvement
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Benefit from sharing with representatives of national organizations that support the engagement of Patient Family Advisers how Advisers in diverse health care settings implement this partnership
Presenters: Hoy, L., Founder/CEO, Patient & Family Centered Care Partners; Zambeaux, A., Senior Project Manager, Institute for Healthcare Improvement; Bourne, L., Director of Networks and Curriculum, Patient & Family Centered Care Partners
Created Date : 9/22/2016
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28th Annual National Forum on Quality Improvement in Health Care M18 A Passport to High-Quality, Affordable Care
Learning Format: Lecture Track: Quality Cost and Value Industrywide, 30% of health care spending—roughly $750 billion per year—is wasted on non-value-added services. Meanwhile, household spending on health care comes in second only to paying for the roof over one’s head, forcing consumer trade-offs between essential needs. This minicourse challenges the ingrained “more is always better” culture and showcases transferable tools, tactics, and promising practices that drive high quality and affordability at Kaiser Permanente, one of America’s leading integrated health care systems. After this presentation, participants will be able to:
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Apply two to four tools, tactics, and promising practices to drive high quality and affordability
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Describe how to accelerate learning and spread through applied data and design excellence
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Articulate the mission-critical interdependence of quality and affordability in health care and engage in networking and open, generative discussions to advance thinking on shared opportunity areas
Presenters: Vartan, A., MPH, Senior Director, Kaiser Permanente; Handley, M., MD, Medical Director for Quality, Group Health Cooperative; Schottinger, J., MD, Assistant Medical Director for Quality & Clinical Analysis, Kaiser Permanente; Bellows, J., PhD, Managing Director, Evaluation and Analytics, Kaiser Permanente; Pugel, S., MD, Physician Director, Resource Stewardship (Georgia Region), Kaiser Permanente; Jones, J., PhD, Vice President, Information Strategy for Care Transformation, Kaiser Permanente; Lippard, T., Medical Director, Geriatrics and Medicare, Colorado Region, Kaiser Permanente M19 Coproducing Health Care Services, Creating Value: Where Do We Start?
Learning Format: Flipped Classroom Track: Quality Cost and Value Health care services are always coproduced, and different organizational configurations enable best value coproduction. Better value requires the ability to customize around particular needs (value shop), standardize around commonly recurring phenomena (value chain), and flexibly facilitate relationships among people with problems and solutions (value network) as individuals and populations work together to minimize the burden of illness. We will explore the coproduction of health care service through these configurations. After this presentation, participants will be able to:
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Describe the differences between a “service” and a “product” in health care and the implications of those differences
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Identify components of the value network model and recognize how the QI community has often dismissed the solution shop for value chain approaches to care
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Discuss the unique and different opportunities for coproduction in the value network model
Presenters: Johnson, J., MSPH, PhD, Professor, Northwestern University; Batalden, P., MD, Professor Emeritus, The Dartmouth Institute; Batalden, M., MD, MPH, Associate Chief Quality Officer, Cambridge Health Alliance
Created Date : 9/22/2016
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28th Annual National Forum on Quality Improvement in Health Care M20 Hospital Flow = Right Care, Right Place, and Right Time
Learning Format: Case Study Track: Quality Cost and Value Providing the "right care, in the right place, at the right time" is essential to ensure safe, high-quality, patient-centered care, and failure to provide such care puts patients at risk for suboptimal care. Poorly managed hospital flow also adds to the already taxing burden on clinicians and staff and diverts their attention from clinical care. Improving hospital flow is a critical lever for increasing value not only for patients and clinicians but for health care systems. After this presentation, participants will be able to:
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Understand and describe how to apply a conceptual framework for system optimization to improve hospital-wide flow
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Utilize an approach for “sense-making” regarding the myriad strategies for improving hospital operations and improving patient flow throughout the hospital
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Analyze contextual factors, change concepts, and successful interventions for creating a sustainable system for system-wide hospital flow so that patients receive the right care, in the right place, at the right time
Presenters: Rutherford, P., RN, MS, Vice President, Institute for Healthcare Improvement; Luther, K., RN, MPM, Vice President, Institute for Healthcare Improvement; Ryckman, F., MD, Sr. Vice President for Medical Operations, Professor of Surgery, Cincinnati Children's Hospital Medical Center; Murrell, K., MD, MBA, APIC, Process Improvement, ED & Hospital Operations, Kaiser Permanente Medical Center M21 Incubators for Profound Organizational Change
Learning Format: Case Study Track: Quality Cost and Value This minicourse will introduce the capabilities for complex adaptive change by creating Organization Technology Development Units (OrgTechDevU), which develop new processes and test new technology before they are mainstreamed on a large scale. Participants will have an opportunity to challenge the complexity in modern health care systems while learning about an OrgTechDevU from expert faculty and the critical skills and leadership required for high performance. Case studies will be used, including the Baldrige Award-winning Charleston Area Medical Center. After this presentation, participants will be able to:
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Identify why system complexity requires us to take a methodical approach such as OrgTechDevU to system design, operation, and improvement
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Propose specific applications of this methodical approach to addressing the quality and affordability of health care
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Exhibit the knowledge and skills to initiate an OrgTechDevU
Presenters: Spear, D., n/a, No Organization; McIlwain, P., VP-Chief Medical Officer, Charleston Area Medical Center; Downes, T., MB BS, MRCP, MBA, MPH (Harvard), Consultant Geriatrician and IHI Fellow, Sheffield Teaching Hospitals
Created Date : 9/22/2016
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28th Annual National Forum on Quality Improvement in Health Care M22 Taking the Leap: Radical System Transformation to Advanced Team-Based Care
Learning Format: Lecture The team-based care model framework has been applied to primary care, specialty care, chronic conditions, and insurance populations. One of the biggest barriers to evolving to a team-based care model has been the reimbursement model in a fee-for-service environment. This session will provide a nine-step framework for developing a sustainable team-based approach to care delivery that is financially viable in any payment environment. After this presentation, participants will be able to:
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Develop a practical framework for implementing an advanced team-based model of patient care that produces Three Wins—a win for the patient, a win for the care team, and a win for the system
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Develop a plan to build the necessary infrastructure for a sustainable model of team-based care across their organization
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Initiate the cultural changes necessary to support radical system redesign and transform their system to team-based care
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Understand the barriers to implementing team-based care and strategies for overcoming these barriers
Presenters: Jerzak, J., MD, Physician, Bellin Health; Lasecki, C., MD, Physician, Bellin Health; Kerscher, K., n/a, No Organization; Wozney, B., MD, Medical Director Population Health, Bellin Health M23 Moving Beyond Budgeting to Become Future-Ready
Learning Format: None Track: Leadership, Quality Cost and Value As the pace of change in business continues to accelerate, how can your organization effectively plan and control your operations? Why do finance’s traditional tools, such as annual budgeting, seem not to work? This minicourse will help you become future-ready by sharing the experiences of many health care organizations in replacing their annual budgeting exercises with relative targets, rolling forecasts, dynamic action plans, and adaptive resource allocations that link to create higher-performing organizations. After this presentation, participants will be able to:
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Identify the key reasons for dissatisfaction with budgeting practices
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Discuss the ways in which the 12 "Beyond Budgeting" principles enable dynamic performance management and the use of a rolling forecast can help an organization become future-ready
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Describe the experience of health care organizations that have successfully implemented these changes
Presenters: Player, S., Managing Director, Beyond Budgeting Round Table
Created Date : 9/22/2016
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28th Annual National Forum on Quality Improvement in Health Care M24 Building an Organization-Wide QI System and Movement
Learning Format: Flipped Classroom Track: Triple Aim for Populations This interactive session will help participants develop a case for change, design a quality improvement program that fits their local context, and develop tactics for engaging and involving all stakeholders in the work. The session will draw from East London NHS Foundation Trust's quality improvement program as a case study, but will also include theories from social movement thinking and large-scale change methods in considering how to embed QI as the organizational philosophy. After this presentation, participants will be able to:
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Develop a case for change to support QI as the vehicle for their organization's mission to improve health and reduce cost
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Identify the key elements of a successful organization-wide quality improvement program
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Develop a strategic narrative and engagement strategy that meets their local context
Presenters: Shah, A., Associate Medical Director (QI) & Consultant forensic psych, East London NHS Foundation Trust (ELFT); Evans, N., CEO, East London NHS Foundation Trust (ELFT); Cleary, K., Chief Medical Officer, East London NHS Foundation Trust (ELFT); Innes, J., Head of Quality Improvement, East London NHS Foundation Trust (ELFT); Gabriel, M., Chairperson, East London NHS Foundation Trust (ELFT); Binfield, P., Senior People Participation Lead, East London NHS Foundation Trust (ELFT); Fitzgerald, M., Director of Governance and Corporate Planning, East London NHS Foundation Trust (ELFT); Bell, L., People Participation Lead, East London NHS Foundation Trust (ELFT) M25 Journey to Population Health for Health Systems
Learning Format: To Be Determined Track: Triple Aim for Populations In this highly participatory Minicourse, health care systems transforming toward population health will assess where they are on the journey, explore key levers from working within their patient population to a total health anchor institution strategy, and learn from health care systems that have advanced on this journey. Participants will then create a practical roadmap for their own transformation. After this presentation, participants will be able to:
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Assess where you are on the journey to population health
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Identify key levers and opportunities to improve health, wellbeing and equity of your patients and communities
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Develop an action plan for your journey
Presenters: Stout, S., MD, MS, Executive External Lead for Health Improvement, Institute for Healthcare Improvement; Norris, T., MDiv, Vice President Total Health, Kaiser Permanente; Choucair, B., n/a, No Organization; Bravo, P., Vice President, Dignity Health
9:00 AM - 4:45 PM S22 22nd Annual International Scientific Symposium on Improving the Quality and Value of Health Care
Monday, December 5: Receptions and Meals
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28th Annual National Forum on Quality Improvement in Health Care 3:30 PM - 6:30 PM ExhOp3 Exhibit Hall Welcome Reception
6:30 PM - 7:00 PM CV Candlelight Vigil: Honoring our Patients, Friends, and Family Members
Monday, December 5: General 7:30 AM - 6:00 PM Book1 Bookstore Open
4:00 PM - 7:00 PM ChpCon 9th Annual IHI Open School Chapter Congress
Tuesday, December 6: Registration 6:30 AM - 5:30 PM Pass3 Conference Pass Print Desk
Tuesday, December 6: Orientation 7:00 AM - 8:00 AM Orient3 National Forum Orientation (Tuesday)
Tuesday, December 6: General 8:00 AM - 3:00 PM CEOGC 2016 CEO and Leadership Summit with General Conference
Tuesday, December 6: Workshop A 9:30 AM - 10:45 AM SW1 Storyboard Walkaround: Addressing the Opioid Epidemic
Learning Format: Storyboard Walkaround Presenters: Koreishi, S., Medical Director Columbia Pacific CCO, CareOregon; Konowalchuk, B., MD, Essentia Health; Bianco, J., MD, Essentia Health; Brewster, M., PharmD, BCPS, Ambulatory Care Coordinator, CareOregon; McPherson, M., PhD, MS, Director, 100 Million Healthier Lives Implementation, Institute for Healthcare Improvement SW2 Storyboard Walkaround: Global Efforts in Achieving Health Equity
Learning Format: Storyboard Walkaround
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28th Annual National Forum on Quality Improvement in Health Care Presenters: Lyndon, M., Clinical Fellow, Ko Awatea; Dvorkin, J., Health Consultant/Project Manager, Institute for Clinical Systems Improvement; Higueras, C., Project Manager, Oregon Community Health Workers Association; Altman, L., Integrated Care Manager, Sydney Childrens Hospital; Anderson, A., Research, Innov | Co-Chair, IHI Diversity/Inclusion Council, Institute for Healthcare Improvement A1 Advancing Health Care for the Transgender Community
Learning Format: To Be Determined Track: Equity Oregon recently made sweeping revisions to Medicaid guidelines on the care of the transgender population, and unprecedented alliances have formed across disciplines, agencies, and health plans to execute these changes. Collaborative care organizations have played a unique role in deploying services and ensuring access to competent providers. This session will discuss the impact of these partnerships on the experience of transgender individuals in Oregon, and participants will learn how to apply similar methods in their environment. After this presentation, participants will be able to:
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Identify the key stakeholders in their community whose alignment would improve outcomes for transgender patients
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Access key resources for ensuring that best standard practices are applied throughout their environment
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Develop confidence in their cultural competence in caring for transgender patients
Presenters: Milano, C., MD, Medical Director, CareOregon A2 Social Needs Interventions from Pilot to Scale
Learning Format: Rapid-Fire Sessions Track: Equity Today social and economic factors affect 70% of health outcomes, and historically marginalized populations are disproportionately affected by these factors. Unmet social needs are associated with higher rates of health care utilization, including ED visits. As we shift toward value-based care, health systems are increasingly reinventing their role and responsibility in addressing patients’ social needs. In this panel, leaders of key health systems will share their experience in piloting and scaling successful social needs strategies. After this presentation, participants will be able to:
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Describe the value proposition for providers—both large and small—in understanding and addressing social needs
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Highlight examples of data-driven strategies used by health care delivery organizations to address patients’ social needs at scale
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Identify actionable lessons and insights from health systems at different points along the journey to scale their social needs strategy
Presenters: Roth, A., RN, MS, MPH, Chief Executive Officer, Contra Costa Health Services; Shah, N., MD, MPH, Senior Vice President & Chief Operating Officer, Kaiser Permanente; Wilson, R., MD FRACP FCICM, Senior Vice President & Chief Medical Officer, New York City Health and Hospitals Corporation; DePompei, P., RN MSN, Vice President, Patient Care Operations, University Hospitals Case Medical Center
Created Date : 9/22/2016
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28th Annual National Forum on Quality Improvement in Health Care A3 Building Capability: The REALLY Big Challenge
Learning Format: Lecture Track: Improvement Capability Does your organization have the structures and processes to achieve your strategic improvement goals? We will present a framework for creating the capacity and capability for improvement among staff as well as patients/service users, emphasizing the major role of an intentional design in leading and guiding your organization’s journey toward excellence. A case study and diagnostic tools, especially the dosing formula, will be provided to help you determine who needs what level of improvement knowledge. After this presentation, participants will be able to:
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Describe the differences between capacity and capability
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Identify the structures and processes that need to be established and sustained in order to build capacity and capability
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Explain how a system can build capacity and capability within multiple audiences and leverage these abilities to achieve sustainable improvement throughout the organization
Presenters: Lloyd, R., PhD, Vice President, Institute for Healthcare Improvement; Shah, A., Associate Medical Director (QI) & Consultant forensic psych, East London NHS Foundation Trust (ELFT); Steinfield, R., MA, Improvement Advisor, Institute for Healthcare Improvement A4 Can Improvement Cause Harm? Ethical Issues in Quality Improvement
Learning Format: Buzz Session Track: Improvement Capability Adherence to an ethical framework is central to quality improvement in health care, yet no standard approach exists. In this highly interactive session, participants will identify the ethical considerations that arise and explore elements of an ethical framework for improvement work through case studies. We will describe a structured approach to reviewing proposed projects, including differentiating human subjects’ research and quality improvement, and provide guidance about acknowledging ethical issues in writings about health care improvement. After this presentation, participants will be able to:
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Identify the components of an ethical framework for quality improvement work
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Describe a structured approach to reviewing health care quality improvement
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Identify ethical challenges in health care quality improvement through analysis of examples of improvement projects
Presenters: Nelson, W., Director, Health and Values Program, The Geisel School of Medicine at Dartmouth; Goodman, D., Instructor in Ob/Gyn; Geisel School of Medicine at Dartmout, Dartmouth Medical School; Ogrinc, G., MD, Physician, White River Junction VA Medical Center
Created Date : 9/22/2016
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28th Annual National Forum on Quality Improvement in Health Care A5 Catalyzing Students and Residents as Agents of Change
Learning Format: To Be Determined Track: Student New and innovative approaches are urgently needed to help providers in office and community settings tackle the challenge of managing the health of populations. Organizations can leverage an underutilized resource by employing the passion and energy of local students. In this session, Open School student leaders will share an organizing approach to health and health care transformation and show participants how to apply these skills to their own local campaign or improvement effort. After this presentation, participants will be able to:
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Describe the design and implementation of a community, action-oriented campaign effort
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Apply organizing skills to their own campaign or improvement effort
Presenters: Hilton, K., JD, MTS, Senior Faculty, ReThink Health; Perlo, J., MPH, Network Director, IHI Open School, Institute for Healthcare Improvement A6 Compare to Learn: Culture in Google and Health Care
Learning Format: To Be Determined Track: Improvement Capability What is it in Google’s culture that explains its phenomenal success? How does the culture of health care organizations compare to Google, and could an in-depth cultural analysis inform health care? Excellence in health care in 2017 will demand that we understand the cultural underpinnings of operational excellence. The presenters, who know Google well and have data on hundreds of health care organizations and experience with thousands, will give participants an opportunity to understand these cultural factors. After this presentation, participants will be able to:
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Discuss the reasons why healthy cultures lead to innovation and operational excellence
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Apply a framework for operational excellence to health care institutions to measure their current state
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Describe specific actions that health care institutions might take to improve their culture
Presenters: Frankel, A., Partner, Safe & Reliable Healthcare; Hippenmeyer, W., n/a, No Organization A7 Delivering Excellence to Moms and Babies
Learning Format: Lecture Track: Improvement Capability A mother delivering her baby can expect a high-quality experience at any Kaiser Permanente (KP) hospital, but the amount of organizational resources consumed depends on where she delivers. Using the IHI 90-Day Cycle as a guide, we entered uncharted KP territory by investigating delivery cost variation from the ground up. In this session, we will share how, by combining quantitative and qualitative approaches, we isolated promising practices that we plan to scale up and spread throughout KP. After this presentation, participants will be able to:
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Discuss the IHI 90-Day Improvement Cycle in detail, including how to avoid common pitfalls
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Describe KP's hypothesis testing journey, including the latest updates on KP's rapid improvement project deployments
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Understand the use of analytics to reduce variation and drive value and quality in their own projects
Presenters: Volodarskiy, M., RN, Regional Director, Kaiser Permanente; Matsunaga, R., Sr. Data Consultant, Kaiser Permanente; Yasumura, L., MD, Kaiser Permanente Hospital A8 Learning Systems for Improvement
Learning Format: To Be Determined Track: Health Plans & Insurers Advancing Improv, Improvement Capability The IHI Breakthrough Series (BTS) model is widely successful in creating a collaborative learning system to spread change ideas where there is a strong degree of belief. Many improvement efforts may not be ready for a BTS collaborative approach, however, and may require different learning system designs. In this session, we will explore different needs and potential learning vehicles to support diverse improvement initiatives. After this presentation, participants will be able to:
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Describe a learning system's various needs and requirements
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Consider the factors that might guide their selection of the right learning system
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Discuss several learning systems designs, including the BTS collaborative approach
Presenters: Williams, D., Ph.D., Executive Director, Institute for Healthcare Improvement; Mate, K., MD, Chief Innovation & Education Officer, Institute for Healthcare Improvement; Spurlock, B., MD, President, Convergence Health Consulting, Inc. A9 Let Your Data Sing
Learning Format: Buzz Session Track: Improvement Capability Data provides the insights to develop improvement strategies, the energy to keep improvement efforts going, and the insights necessary to evaluate the impact of the improvement work. But often data summaries and reports are dry and complex and do not effectively communicate the improvement story. This workshop will explore approaches to bringing your improvement data to life and presenting the story that your data is trying to tell. After this presentation, participants will be able to:
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Develop approaches to communicating the results of improvement efforts
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Produce time series charts that tell the story of their improvement journey
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Present improvement reports to executives and boards that lead to learning and action
Presenters: Provost, L., MS, Statistician, Associates in Process Improvement; Power, M., PhD, MPH, CEO, Haelo
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28th Annual National Forum on Quality Improvement in Health Care A10 Running Successful Collaboratives Around the Globe
Learning Format: Lecture Track: Health Plans & Insurers Advancing Improv, Improvement Capability The need for rapid and sustainable change in health care is urgent. IHI's Breakthrough Series (BTS) collaboratives provide a powerful tool for spreading improvements when established design principles are used and common pitfalls are avoided. This interactive session covers topic selection, change packages and measurement systems, engaging teams, and running robust learning sessions and action periods. A case study will focus on innovative adaptations to the model in Africa to work around bottlenecks and achieve great results. After this presentation, participants will be able to:
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Apply established design principles for successful BTS collaboratives
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Diagnose and address common challenges in using the BTS method
Presenters: McCutcheon Adams, K., MSW, LICSW, Director, Institute for Healthcare Improvement; Tshabalala, M., RNM, BBA, MPH, Regional Director; Southern Africa, Institute for Healthcare Improvement; Butts-Dion, S., Improvement Advisor, Butts-Dion Consulting, Inc. A11 Keeping Your People Sane: Team-Building Activities
Learning Format: Buzz Session Track: Joy in Work Would you like to improve morale and productivity in your workplace? We will share our efforts to engage clinicians and faculty in “outside-the-box” team-building activities that have broken barriers and improved trust among staff with various levels of training. Leaders from the Hofstra Northwell School of Medicine’s Family Medicine Residency Program at Southside Hospital will describe various activities that combat burnout and allow more joy in the workplace. After this presentation, participants will be able to:
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Identify the risks of failing to promote wellness in the workplace
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List team-building activities that can improve morale, trust, teamwork, and productivity
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Design their own curriculum of team-building activities based on available resources
Presenters: Iroku-Malize, T., MD, MPH, MBA, Chair Dept of Family Medicine, Northwell Health; Grissom, M., Director of Behavioral Science, Hofstra Northwell School of Medicine A12 Emerging Best Practices to Sustain Improvement
Learning Format: Buzz Session Track: Leadership This session will describe the management practices adopted by top-performing health care organizations to sustain improvements that support highly reliable, safe, and efficient care. We will discuss the "management system architecture" and key drivers of high-performance management that emerged from our study of 10 leading acute-care organizations: daily standard work; formal accountability; frequent, data-grounded communication; problem-solving methodology; protocols for escalating problems; and positive trust relationships among managers and staff. After this presentation, participants will be able to:
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Distinguish between management for quality control and management for quality improvement
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Describe standard high-performance management practices at three levels of management
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Describe recommended approaches to implementing a high-performance management system
Presenters: Scoville, R., PhD, Improvement Advisor/Consultant, Institute for Healthcare Improvement; Little, K., Ph.D, Principal, Informing Ecological Design, LLC; Rakover, J., Research Associate, Institute for Healthcare Improvement; Griffee, L., Director of Lean Operations, Greater Baltimore Medical Center; Holder, B., RN, BSN, LHRM, CAPA, QI/Infection Control/Safety Officer, Andrews Institute Ambulatory Surgery Center LLC A13 Personal Mastery for Transformational Leadership
Learning Format: Case Study Track: Leadership Transformational change depends on how fast and far people shift roles and ways of thinking and relating. Within the context of the emotional tension and resistance that are human and ubiquitous constraints, leaders are faced with the difficult tasks of simultaneously managing their own reactions, standing firm on decisions, and individually engaging others. In this session, a case study will be used to present methods that enhance "personal mastery"—the way to achieve desired results and creative relationships. After this presentation, participants will be able to:
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Explain how to identify and respond effectively to personal reactions and reactions in others that may interfere with progress
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Identify strategies for reflection and communication that facilitate moving from reactivity to creativity
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Define ways to exercise authority that help to preserve positive engagement
Presenters: Baker, N., MD, Principal, Neil Baker Consulting and Coaching A14 Exploring the Challenge of Low-Volume Surgery and Quality
Learning Format: Controversy Panel Track: Patient Safety Are you facing the challenge of safely providing low-volume surgery? In this session, the panel will review the research as well as the competing priorities of two systems that have faced this challenge, including community access, surgical safety, surgeon competency, career satisfaction, and the approaches being used. We will describe the path taken by each system to integrate a culture of safety while balancing other priorities. After this presentation, participants will be able to:
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Explore competing patient, surgeon, and community priorities for low-volume surgery and safety
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Understand the approaches taken by two systems to address patient safety, surgeon/surgical team maintenance of skills and career satisfaction, and patient access and convenience
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Describe feasible approaches to low-volume surgery and safety in their own system
Presenters: Elster, E., Professor and Chair, USUHS; Kanter, M., MD, Medical Director, Quality & Clinical Analysis, Kaiser Permanente; Chase, A., BS, MS, Consultant, LLC, No Organization; York, G., Surgical Services Consultant - USAF Surgeon General, Air Force Medical Operations Agency; Rush, R., MD, Surgeon, Madigan Army Medical Center; Cordts, P., MD, Deputy Director for Healthcare Operations, Department of Defense A15 High Reliability and Robust Process Improvement
Learning Format: Lecture Track: Patient Safety High-reliability health care is now considered a realizable goal, but the question of how to achieve it remains. Robust Process Improvement (RPI) provides a high-reliability framework that enables customized solutions to serious problems insufficiently addressed by checklists. Instead of QI projects, RPI produces standard work for ongoing safety and quality gains. Participants will learn a new and more effective way to deliver results that for the next generation of best practices. After this presentation, participants will be able to:
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Differentiate between RPI and traditional approaches to health care quality improvement and understand how RPI produces new standard work to yield permanent safety and quality improvements
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Differentiate between the problems that can be addressed with checklists and the problems for which RPI is the best approach
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Identify why and how quality and safety problems vary among different health care settings and organizations and how to implement high-reliability solutions
Presenters: Shabot, M., MD, FACS, FCCM, FACMI, Executive Vice President/Chief Clinical Officer, Memorial Hermann; Chassin, M., MD, FACP, MPP, MPH, President and Chief Executive Officer, The Joint Commission A16 Long-Term-Care Facilities as Arenas for Compassionate Quality Improvement Work
Learning Format: Lecture Track: Patient Safety Does your staff have the necessary personal information about their patients 24/7? Centering its care on compassion and rapid transfer of critical information, Norlandia Oppsalhjemmet, a nursing home in Oslo, extensively uses well-tested dialogue tools with relatives, including living wills, as well as huddleboard meetings for individualized care and risk reduction. This workshop will discuss the tools that have proven their value during seven years of systematic QI work while making work meaningful and joyful for the staff. After this presentation, participants will be able to:
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Identify QI methods that have proven helpful in a long-term care facility
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Understand how emphasizing the individuality of residents puts compassion into care
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Recognize the benefit of extensive dialogue with and preparation of relatives
Presenters: Ore, S., Nursing Home Physician, The Norwegian Medical Association; Bonite, K., Registered Nurse, Norlandia AS, avdeling Oppsalhjemmet A17 Reliable Diagnosis and Tracking in Primary Care
Learning Format: Case Study Track: Patient Safety Many primary care practices struggle to provide reliable systems for diagnosis and tracking patients and referrals. This session will review the impact of “hidden” human stressors on diagnosis; lessons from the HMS Academic Innovations Collaborative on creating effective, reliable closed-loop systems; and strategies that any organization can use to drive similar improvements. Discussion will include examples related to preventive screenings and presentation of red flag symptoms in diverse primary care settings. After this presentation, participants will be able to:
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Understand the range of human factors that interfere with and degrade diagnostic accuracy and timeliness
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Identify patient-centered processes to improve the tracking and follow-up of screening and diagnostic testing
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Identify specific changes that can be tested to create more reliable processes at their own organization
Presenters: Hunt, L., MEd, Director, Health Systems Transformation, Harvard Medical School Center for Primary Care; Cohen, D., Chief Medical Officer, Datix (USA) Inc; Graber, M., President, Society to Improve Diagnosis in Medicine A18 Surgical Interventions in Birth: Global Perspectives
Learning Format: Rapid-Fire Sessions Track: Patient Safety While the WHO recommends a Cesarean section rate of 15%, many countries struggle with overuse, underuse, or misuse. This session will share how QI initiatives are being designed, tested, and implemented to determine right care, at the right time, in the right context. We will share design elements and current results from Brazil, the US, and India and support interaction to enhance learning of what is needed to improve maternal and neonatal health. After this presentation, participants will be able to:
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Understand the variation in nulliparous cesarean rates from a regional and provider perspective
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Discuss the influence of arbitrary targets on delivering the right care at the right time to patients
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Identify strategies for developing and adapting improvement methods in local contexts around the world
Presenters: Leavitt Gullo, S., RN, BSN, MS, Director, Institute for Healthcare Improvement; Borem, P., Director Projects Latin America, Institute for Healthcare Improvement; Mehndiratta, A., MBBS,DCH,DNB,MPH, Faculty, Institute for Healthcare Improvement; Barker, P., MBChB,MD, Senior Vice President, Institute for Healthcare Improvement
Created Date : 9/22/2016
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28th Annual National Forum on Quality Improvement in Health Care A19 Are We Improving the Patient Experience?
Learning Format: Controversy Panel Track: Person- and Family-Centered Care Patient-centered care (PCC) is on everyone's priority list, and yet the word on the street about health system experiences remains predominantly negative. Is your work making a difference to the majority of patients coming through your doors? This expert panel will discuss the gaps and disconnects and explore practices that truly matter in the patient and family experience. This session will deliver a lively, informative discussion among people with passion and experience in PCC. After this presentation, participants will be able to:
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Examine the relationship between patient-centered care and patient experience
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Identify gaps in the improvement work being done in PCC and its actual effects on patients
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Share high-leverage tactics for transforming the experience of patients and their families
Presenters: Wolf, J., PhD, President, The Beryl Institute; Mullen, C., Doctoral Candidate/Associate Instructor, Indiana University Purdue University Indianapolis; Hayward, M., Lead, Patient and Family Engagement, Institute for Healthcare Improvement; Srisaneha, E., Project Manager, Southcentral Foundation; Andrews, D., Patient Advisor, Georgia Regents Medical Center A20 What Matters to You? Using Co-design to Revolutionize Patient Experience
Learning Format: To Be Determined Track: Person- and Family-Centered Care In this interactive workshop, participants will use IHI’s Always Events framework to co-design an improvement effort to improve outcomes that matter to patients. Participants will complete prework to learn the Always Events framework and rules of radical redesign. Onsite, Sutter Health will share their journey using these frameworks to transform patient experience and promote wellbeing. The session will conclude with small group coaching focused on creating an Always Event for your organization. Come with an improvement idea in mind and get ready to roll up your sleeves and co-design! After this presentation, participants will be able to:
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Explore methods for determining what matters to patients, service users, and care partners.
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Describe the evolution of the Sutter Health Always Event designed to transform the patient experience and promote well being.
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Illustrate examples of adoption and spread of our Always Event across the Sutter Health continuum of care.
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Initiate an action plan to begin the steps to co-design an Always Event in your setting
Presenters: Gunther-Murphy, C., Executive Director, Institute for Healthcare Improvement; Mather, C., MA, Senior Project Manager, Institute for Healthcare Improvement; Suter, P., Clinical Director, Sutter Health; Hennessey, B., RN, BSN, MSN, Executive Director Sutter Center for Integrated Care, Sutter VNA and Hospice
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28th Annual National Forum on Quality Improvement in Health Care A21 Patients as Partners: New Ways to Design Care
Learning Format: Rapid-Fire Sessions Track: Person- and Family-Centered Care Hear firsthand from patients and staff about leading-edge practices and mindsets that are transforming care and experience. Gain insight on how to co-design with patients to improve performance and bring greater meaning, purpose, and value to your team and strategic priorities. Inspirational case studies will give you starter tools for applying design thinking and quality improvement to gather deep insights and accelerate learning and spread in your organization. After this presentation, participants will be able to:
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Describe leading-edge ways to partner with patients, families, and caregivers to design and improve care
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Understand the essential role of design thinking in accelerating learning and driving quality improvement
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Access tools, methods, and mindsets for the strategic priorities in their own initiatives to improve and innovate
Presenters: Neuwirth, E., PhD, Senior Director, Innovation Design, Kaiser Permanente's Care Management Institute; McCarthy, C., MPH/MBA, Director, Innovation Learning Network, Kaiser Permanente; Martinez, R., Patient Advisor, Kaiser Permanente South Sacramento; Harvey, P., RN, Sr. Vice President, Kaiser Permanente A22 Stop Seeing the Patient, Start Seeing the Person
Learning Format: To Be Determined Track: Person- and Family-Centered Care In an ever-demanding clinical and technical environment, we are continuously challenged to find ways to truly connect with patients. Traditional perceptions are flipped when we ask patients and their families, "What matters to you?" Hear how a simple tool has transformed care and the power of real patient stories has led to the spread of "What Matters to Me" from pediatrics and the care of older people to wide use across the NHS in Scotland. After this presentation, participants will be able to:
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Describe the tools and techniques, inspired by real patient stories, that are required to implement genuinely person-centered care
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Develop their own approach to using "What Matters to Me" in patient-centered care by asking what matters, listening to what matters, and doing what matters
Presenters: Rodgers, J., n/a, No Organization
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28th Annual National Forum on Quality Improvement in Health Care A23 ACO, P4P, MACRA: From Acronyms to the Triple Aim
Learning Format: Rapid-Fire Sessions Track: Quality Cost and Value Participants in this session will learn the building blocks for creating a high-value, patient-centered, and affordable delivery system that maintains joy in work. Emory Healthcare Network leaders will present, in rapid-fire format, the key elements of their population management platform and offer important administrative, clinical, analytical, and value-related lessons. Participants will leave with a framework for developing their own value-based delivery platform. After this presentation, participants will be able to:
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Identify the necessary fundamentals for deploying a value-based care delivery model
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Understand the important elements of creating an effective population management platform
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Apply key administrative, clinical, operational, and data-related lessons in the pursuit of value
Presenters: Gitomer, R., MD, President & CQO, Emory Healthcare Network; Koch, K., Director of Value Management, Emory Healthcare; Galatas, T., Corporate Director, Emory Healthcare Network, Emory Healthcare; Landor, M., RN MSN CNS ANP-C, Manager of EHN Care Coordination, Emory Healthcare A24 Quality Improvement for Social Needs Interventions in Health Care
Learning Format: Rapid-Fire Sessions Track: Equity, Quality Cost and Value Health care delivery systems increasingly recognize that health is affected by social conditions outside hospital and clinic walls. This awareness has inspired efforts to systematically identify patients’ social needs and build linkages to "upstream" community resources. This session will focus on the growing opportunities to determine how to measure and enhance the efficiency, efficacy, and scalability of such services, featuring leading organizations that use QI to optimize patient and population health by proactively engaging partners and aligning with payers. After this presentation, participants will be able to:
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Define a role for hospitals, clinics, and health care providers in addressing “upstream” social needs
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Identify current knowledge gaps on how to best measure and enhance the efficiency, efficacy, and scalability of such services
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Describe how leading organizations identify and act on social needs in order to optimize patient and population health
Presenters: Kahn, R., MD MPH, Professor, Associate Chair for Community Health, Cincinnati Children's Hospital Medical Center; Goldstein, Z., Principal, Innovation, Health Leads; Beck, A., MD, MPH, Pediatrician, Cincinnati Children's Hospital Medical Center; Manchanda, R., MD MPH, Founder, HealthBegins, HealthBegins; Mossman, N., MPH, Program Mgr, Payment Reform/Social Determinants of Health, OCHIN
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28th Annual National Forum on Quality Improvement in Health Care A25 What Is a Patient's Chance of Survival from Sepsis in Your Organization?
Learning Format: Lecture Track: Quality Cost and Value Sepsis can have up to a 30% mortality rate if it goes undetected and is not treated rapidly. In this session, learn how one organization strove to achieve a 90% chance of survival from sepsis, or greater, for its patients across an entire health system, with the goal of ensuring that the chance of survival from sepsis would be 10% or less for anyone admitted to any hospital. After this presentation, participants will be able to:
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Define the elements of a clinical effectiveness program to decrease variation and improve sepsis care
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Understand where variance occurs in the treatment of sepsis and how to decrease it
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Describe the role of the sepsis nurse in early identification of sepsis, treatment, and standardization of sepsis care
Presenters: Alvarez, T., MSN, RN, CCRN-K, Executive Director, Performance Improvement, Providence St. Joseph Health; Vovan, A., MD, MBA, FCCM, Exec Med Dir Clinical Effectiveness, St Joseph Hoag Health; Myran, R., MSN, RN, PCCN, Sepsis Coordinator, HOAG MEMORIAL HOSPITAL PRESBYTERIAN; Jasper, E., Director, Performance Improvement, St Joseph Health System A26 A Systems Approach to the Opioid Crisis
Learning Format: Case Study Track: Triple Aim for Populations Even as significant resources are being channeled toward the opioid crisis (responsible for 28,647 deaths in 2014), it persists and worsens. We believe it is necessary to replace isolated efforts to intervene with a system approach across an entire community, coordinated between health care, law enforcement, and public health stakeholders. This session will describe IHI’s system approach to addressing the opioid crisis and highlight examples from communities that are reducing opioid-related morbidity and mortality. After this presentation, participants will be able to:
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Describe a system approach to addressing the opioid crisis, including the roles of different stakeholders
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Understand how communities have successfully deployed multiple strategies to reduce opioid-related morbidity and mortality
Presenters: Laderman, M., MSPH, Senior Research Associate, Institute for Healthcare Improvement; Martin, L., MSPH, Executive Director, Institute for Healthcare Improvement
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28th Annual National Forum on Quality Improvement in Health Care A27 From Clinical to Social: Redefining What Counts as Health Care
Learning Format: Rapid-Fire Sessions Track: Equity, Triple Aim for Populations Until now, traditional health care has not addressed the social and environmental factors that account for 70% of health outcomes. From the recent release of the CMS Accountable Health Communities model to the imperative to better understand and treat the needs of their most complex populations, health systems are redefining what constitutes health care. This session will explore innovative tools to assess social needs and ways to leverage new and existing services in the housing, food, social isolation, and transportation arenas to augment clinical care. After this presentation, participants will be able to:
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Contextualize recent strong market signals around addressing patients' social needs in the broader shift toward value-based care models
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Discuss methods and tools to identify the factors getting between people and optimal outcomes and creative ways to address them
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Apply lessons and strategies learned to their own organization’s efforts
Presenters: Englert, R., Sr. Business Leader, Community Health Innovation Programs, CareOregon; Perla, R., President, Health Leads; Moore, L., MD, Senior Medical Director, 3M Health Information Systems, Inc.; Lewis, N., MS, Executive Director, Institute for Healthcare Improvement A28 Enhanced Recovery After Colorectal Surgery
Learning Format: Case Study Track: Triple Aim for Populations Our community medical center implemented an Enhanced Recovery After Surgery (ERAS) protocol aimed at decreasing surgical stress to colorectal patients and reducing hospital length of stay and morbidity. The ERAS protocol was based on multidisciplinary input from surgeons, nurses, pharmacists, anesthesiologists, and resident surgeons. With the ERAS program, patients have experienced a quicker advancement of diet with reduced analgesia usage and shorter length of stay and without a significant difference in morbidity or mortality. After this presentation, participants will be able to:
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Implement a perioperative platform for a standardized, evidence-based ERAS protocol for all patients undergoing elective colorectal resections
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Assess whether successful adoption of an ERAS protocol reduces length of stay and postoperative complications after elective surgery
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Compare outcomes reported in the literature with our institutional outcomes with an ERAS protocol
Presenters: Shapiro, S., Surgeon, Gundersen Health System; Bray, M., Resident Surgeon, Gundersen Health System
Created Date : 9/22/2016
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28th Annual National Forum on Quality Improvement in Health Care A29 How to Successfully Implement the Triple Aim in a Community
Learning Format: Case Study Track: Triple Aim for Populations Pueblo's six-year pursuit of the Triple Aim has achieved remarkable results, lowering teen pregnancy rates by 40% and preventable elderly readmissions by 50%. Even with these successes, however, there are many obstacles to overcome to fully implement the Triple Aim in Pueblo. We will share the plan that we have used so that other communities can copy the formula and avoid our mistakes in achieving the Triple Aim for a community. After this presentation, participants will be able to:
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Identify the major components of successful implementation of the Triple Aim in a community as well as the avoidable pitfalls
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Create action steps for their own community to start or advance their thinking on how to implement the Triple Aim for their population
Presenters: Whittington, J., MD, IHI Lead Faculty, Triple Aim Initiative, Institute for Healthcare Improvement; Guy, M., MPA, Executive Director, Pueblo Triple Aim Corporation A30 Population Health in the Military Health System
Learning Format: To Be Determined Track: Triple Aim for Populations The Military Health System (MHS) has been engaged in population health for almost two decades. This presentation will cover how the program has managed to serve the military population this long by being scalable, extensible, and flexible. The session will include quality measurement, registries, predictive analytics, metadata tagging, forecasting, and real-time clinical decision support for high-risk populations. After this presentation, participants will be able to:
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Discuss the MHS journey with population health and the role of enterprise-mindedness in encouraging innovation and flexibility for medical management
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Describe how predictive analytics as a platform provides clear insight into improvement opportunities for the coordination and delivery of health care
Presenters: Carnahan, D., MD, MSCE, Enterprise Intelligence Branch Chief, DHA / Gov AFree Workshop A Free Time
Tuesday, December 6: Workshop B 11:15 AM - 12:30 PM SW3 Storyboard Walkaround: Transforming the Patient Experience through Technology
Learning Format: Storyboard Walkaround Presenters: Curatulo, L., n/a, No Organization; Embree, P., MBA, Senior Director, PFCC Innovation Center of UPMC, University of Pittsburgh Medical Center (UPMC); Knight, D., n/a, No Organization; Tambala, J., Project Officer, MaiKhanda; Meisinger, K., MD, Medical Director, Cambridge Health Alliance
Created Date : 9/22/2016
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28th Annual National Forum on Quality Improvement in Health Care SW4 Storyboard Walkaround: Patient, Team, System, Payer: The Quality Pillars
Learning Format: Storyboard Walkaround Track: Health Plans & Insurers Advancing Improv, Quality Cost and Value The American College of Physicians’ quality improvement network has implemented projects in pain management, adult immunizations, and diabetes, producing improvements in care, outcomes, costs, and provider well-being—the quadruple aim. The ACP programs focus on patient engagement, team-based care, and system/payer support and alignment. Project leaders will describe the program paradigm and give concrete examples of strategies and outcomes that reveal the power of physician-led QI that engages the patient, team, system, and payer. After this presentation, participants will be able to:
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Link practice transformation initiatives with the QI pillars—the patient, team, system, and payer—to achieve sustained engagement and improvement
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Understand the drivers for practice transformation success based on insights from ACP’s quality improvement network leaders
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Identify opportunities to link QI programs to the quadruple aim so as to improve care, outcomes, value, and provider well-being
Presenters: Andrieni, J., MD, FACP, Vice President, Population Health & Primary Care, Houston Methodist; Brown, M., MD, MD, Rush University Medical Center; Wubu, S., Senior Associate, Quality Improvement, American College of Physicians; Peskin, S., MD, MBA,FACP, Executive Medical Director, Horizon Blue Cross Blue Shield of New Jersey; Hall, L., Ph.D., Director, Center for Quality, American College of Physicians B1 Advancing Health Care for the Transgender Community
Learning Format: To Be Determined Track: Equity Oregon recently made sweeping revisions to Medicaid guidelines on the care of the transgender population, and unprecedented alliances have formed across disciplines, agencies, and health plans to execute these changes. Collaborative care organizations have played a unique role in deploying services and ensuring access to competent providers. This session will discuss the impact of these partnerships on the experience of transgender individuals in Oregon, and participants will learn how to apply similar methods in their environment. After this presentation, participants will be able to:
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Identify the key stakeholders in their community whose alignment would improve outcomes for transgender patients
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Access key resources for ensuring that best standard practices are applied throughout their environment
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Develop confidence in their cultural competence in caring for transgender patients
Presenters: Milano, C., MD, Medical Director, CareOregon
Created Date : 9/22/2016
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28th Annual National Forum on Quality Improvement in Health Care B2 Social Needs Interventions from Pilot to Scale
Learning Format: Rapid-Fire Sessions Track: Equity Today social and economic factors affect 70% of health outcomes, and historically marginalized populations are disproportionately affected by these factors. Unmet social needs are associated with higher rates of health care utilization, including ED visits. As we shift toward value-based care, health systems are increasingly reinventing their role and responsibility in addressing patients’ social needs. In this panel, leaders of key health systems will share their experience in piloting and scaling successful social needs strategies. After this presentation, participants will be able to:
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Describe the value proposition for providers—both large and small—in understanding and addressing social needs
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Highlight examples of data-driven strategies used by health care delivery organizations to address patients’ social needs at scale
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Identify actionable lessons and insights from health systems at different points along the journey to scale their social needs strategy
Presenters: Roth, A., RN, MS, MPH, Chief Executive Officer, Contra Costa Health Services; Shah, N., MD, MPH, Senior Vice President & Chief Operating Officer, Kaiser Permanente; Wilson, R., MD FRACP FCICM, Senior Vice President & Chief Medical Officer, New York City Health and Hospitals Corporation; DePompei, P., RN MSN, Vice President, Patient Care Operations, University Hospitals Case Medical Center B3 Building Capability: The REALLY Big Challenge
Learning Format: Lecture Track: Improvement Capability Does your organization have the structures and processes to achieve your strategic improvement goals? We will present a framework for creating the capacity and capability for improvement among staff as well as patients/service users, emphasizing the major role of an intentional design in leading and guiding your organization’s journey toward excellence. A case study and diagnostic tools, especially the dosing formula, will be provided to help you determine who needs what level of improvement knowledge. After this presentation, participants will be able to:
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Describe the differences between capacity and capability
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Identify the structures and processes that need to be established and sustained in order to build capacity and capability
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Explain how a system can build capacity and capability within multiple audiences and leverage these abilities to achieve sustainable improvement throughout the organization
Presenters: Lloyd, R., PhD, Vice President, Institute for Healthcare Improvement; Shah, A., Associate Medical Director (QI) & Consultant forensic psych, East London NHS Foundation Trust (ELFT); Steinfield, R., MA, Improvement Advisor, Institute for Healthcare Improvement
Created Date : 9/22/2016
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28th Annual National Forum on Quality Improvement in Health Care B4 Can Improvement Cause Harm? Ethical Issues in Quality Improvement
Learning Format: Buzz Session Track: Improvement Capability Adherence to an ethical framework is central to quality improvement in health care, yet no standard approach exists. In this highly interactive session, participants will identify the ethical considerations that arise and explore elements of an ethical framework for improvement work through case studies. We will describe a structured approach to reviewing proposed projects, including differentiating human subjects’ research and quality improvement, and provide guidance about acknowledging ethical issues in writings about health care improvement. After this presentation, participants will be able to:
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Identify the components of an ethical framework for quality improvement work
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Describe a structured approach to reviewing health care quality improvement
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Identify ethical challenges in health care quality improvement through analysis of examples of improvement projects
Presenters: Nelson, W., Director, Health and Values Program, The Geisel School of Medicine at Dartmouth; Goodman, D., Instructor in Ob/Gyn; Geisel School of Medicine at Dartmout, Dartmouth Medical School; Ogrinc, G., MD, Physician, White River Junction VA Medical Center B5 Catalyzing Students and Residents as Agents of Change
Learning Format: To Be Determined Track: Student New and innovative approaches are urgently needed to help providers in office and community settings tackle the challenge of managing the health of populations. Organizations can leverage an underutilized resource by employing the passion and energy of local students. In this session, Open School student leaders will share an organizing approach to health and health care transformation and show participants how to apply these skills to their own local campaign or improvement effort. After this presentation, participants will be able to:
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Describe the design and implementation of a community, action-oriented campaign effort
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Apply organizing skills to their own campaign or improvement effort
Presenters: Hilton, K., JD, MTS, Senior Faculty, ReThink Health; Perlo, J., MPH, Network Director, IHI Open School, Institute for Healthcare Improvement B6 Compare to Learn: Culture in Google and Health Care
Learning Format: To Be Determined Track: Improvement Capability What is it in Google’s culture that explains its phenomenal success? How does the culture of health care organizations compare to Google, and could an in-depth cultural analysis inform health care? Excellence in health care in 2017 will demand that we understand the cultural underpinnings of operational excellence. The presenters, who know Google well and have data on hundreds of health care organizations and experience with thousands, will give participants an opportunity to understand these cultural factors. After this presentation, participants will be able to:
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Discuss the reasons why healthy cultures lead to innovation and operational excellence
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Apply a framework for operational excellence to health care institutions to measure their current state
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Describe specific actions that health care institutions might take to improve their culture
Presenters: Frankel, A., Partner, Safe & Reliable Healthcare; Hippenmeyer, W., n/a, No Organization B7 Delivering Excellence to Moms and Babies
Learning Format: Lecture Track: Improvement Capability A mother delivering her baby can expect a high-quality experience at any Kaiser Permanente (KP) hospital, but the amount of organizational resources consumed depends on where she delivers. Using the IHI 90-Day Cycle as a guide, we entered uncharted KP territory by investigating delivery cost variation from the ground up. In this session, we will share how, by combining quantitative and qualitative approaches, we isolated promising practices that we plan to scale up and spread throughout KP. After this presentation, participants will be able to:
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Discuss the IHI 90-Day Improvement Cycle in detail, including how to avoid common pitfalls
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Describe KP's hypothesis testing journey, including the latest updates on KP's rapid improvement project deployments
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Understand the use of analytics to reduce variation and drive value and quality in their own projects
Presenters: Volodarskiy, M., RN, Regional Director, Kaiser Permanente; Matsunaga, R., Sr. Data Consultant, Kaiser Permanente; Yasumura, L., MD, Kaiser Permanente Hospital B8 Learning Systems for Improvement
Learning Format: To Be Determined Track: Health Plans & Insurers Advancing Improv, Improvement Capability The IHI Breakthrough Series (BTS) model is widely successful in creating a collaborative learning system to spread change ideas where there is a strong degree of belief. Many improvement efforts may not be ready for a BTS collaborative approach, however, and may require different learning system designs. In this session, we will explore different needs and potential learning vehicles to support diverse improvement initiatives. After this presentation, participants will be able to:
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Describe a learning system's various needs and requirements
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Consider the factors that might guide their selection of the right learning system
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Discuss several learning systems designs, including the BTS collaborative approach
Presenters: Williams, D., Ph.D., Executive Director, Institute for Healthcare Improvement; Mate, K., MD, Chief Innovation & Education Officer, Institute for Healthcare Improvement; Spurlock, B., MD, President, Convergence Health Consulting, Inc.
Created Date : 9/22/2016
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28th Annual National Forum on Quality Improvement in Health Care B9 Let Your Data Sing
Learning Format: Buzz Session Track: Improvement Capability Data provides the insights to develop improvement strategies, the energy to keep improvement efforts going, and the insights necessary to evaluate the impact of the improvement work. But often data summaries and reports are dry and complex and do not effectively communicate the improvement story. This workshop will explore approaches to bringing your improvement data to life and presenting the story that your data is trying to tell. After this presentation, participants will be able to:
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Develop approaches to communicating the results of improvement efforts
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Produce time series charts that tell the story of their improvement journey
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Present improvement reports to executives and boards that lead to learning and action
Presenters: Provost, L., MS, Statistician, Associates in Process Improvement; Power, M., PhD, MPH, CEO, Haelo B10 Running Successful Collaboratives Around the Globe
Learning Format: Lecture Track: Health Plans & Insurers Advancing Improv, Improvement Capability The need for rapid and sustainable change in health care is urgent. IHI's Breakthrough Series (BTS) collaboratives provide a powerful tool for spreading improvements when established design principles are used and common pitfalls are avoided. This interactive session covers topic selection, change packages and measurement systems, engaging teams, and running robust learning sessions and action periods. A case study will focus on innovative adaptations to the model in Africa to work around bottlenecks and achieve great results. After this presentation, participants will be able to:
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Apply established design principles for successful BTS collaboratives
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Diagnose and address common challenges in using the BTS method
Presenters: McCutcheon Adams, K., MSW, LICSW, Director, Institute for Healthcare Improvement; Tshabalala, M., RNM, BBA, MPH, Regional Director; Southern Africa, Institute for Healthcare Improvement; Butts-Dion, S., Improvement Advisor, Butts-Dion Consulting, Inc. B11 Keeping Your People Sane: Team-Building Activities
Learning Format: Buzz Session Track: Joy in Work Would you like to improve morale and productivity in your workplace? We will share our efforts to engage clinicians and faculty in “outside-the-box” team-building activities that have broken barriers and improved trust among staff with various levels of training. Leaders from the Hofstra Northwell School of Medicine’s Family Medicine Residency Program at Southside Hospital will describe various activities that combat burnout and allow more joy in the workplace. After this presentation, participants will be able to:
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Identify the risks of failing to promote wellness in the workplace
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List team-building activities that can improve morale, trust, teamwork, and productivity
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Design their own curriculum of team-building activities based on available resources
Presenters: Iroku-Malize, T., MD, MPH, MBA, Chair Dept of Family Medicine, Northwell Health; Grissom, M., Director of Behavioral Science, Hofstra Northwell School of Medicine B12 Emerging Best Practices to Sustain Improvement
Learning Format: Buzz Session Track: Leadership This session will describe the management practices adopted by top-performing health care organizations to sustain improvements that support highly reliable, safe, and efficient care. We will discuss the "management system architecture" and key drivers of high-performance management that emerged from our study of 10 leading acute-care organizations: daily standard work; formal accountability; frequent, data-grounded communication; problem-solving methodology; protocols for escalating problems; and positive trust relationships among managers and staff. After this presentation, participants will be able to:
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Distinguish between management for quality control and management for quality improvement
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Describe standard high-performance management practices at three levels of management
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Describe recommended approaches to implementing a high-performance management system
Presenters: Scoville, R., PhD, Improvement Advisor/Consultant, Institute for Healthcare Improvement; Little, K., Ph.D, Principal, Informing Ecological Design, LLC; Rakover, J., Research Associate, Institute for Healthcare Improvement; Griffee, L., Director of Lean Operations, Greater Baltimore Medical Center; Holder, B., RN, BSN, LHRM, CAPA, QI/Infection Control/Safety Officer, Andrews Institute Ambulatory Surgery Center LLC B13 Personal Mastery for Transformational Leadership
Learning Format: Case Study Track: Leadership Transformational change depends on how fast and far people shift roles and ways of thinking and relating. Within the context of the emotional tension and resistance that are human and ubiquitous constraints, leaders are faced with the difficult tasks of simultaneously managing their own reactions, standing firm on decisions, and individually engaging others. In this session, a case study will be used to present methods that enhance "personal mastery"—the way to achieve desired results and creative relationships. After this presentation, participants will be able to:
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Explain how to identify and respond effectively to personal reactions and reactions in others that may interfere with progress
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Identify strategies for reflection and communication that facilitate moving from reactivity to creativity
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Define ways to exercise authority that help to preserve positive engagement
Presenters: Baker, N., MD, Principal, Neil Baker Consulting and Coaching
Created Date : 9/22/2016
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28th Annual National Forum on Quality Improvement in Health Care B14 Exploring the Challenge of Low-Volume Surgery and Quality
Learning Format: Controversy Panel Track: Patient Safety Are you facing the challenge of safely providing low-volume surgery? In this session, the panel will review the research as well as the competing priorities of two systems that have faced this challenge, including community access, surgical safety, surgeon competency, career satisfaction, and the approaches being used. We will describe the path taken by each system to integrate a culture of safety while balancing other priorities. After this presentation, participants will be able to:
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Explore competing patient, surgeon, and community priorities for low-volume surgery and safety
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Understand the approaches taken by two systems to address patient safety, surgeon/surgical team maintenance of skills and career satisfaction, and patient access and convenience
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Describe feasible approaches to low-volume surgery and safety in their own system
Presenters: Elster, E., Professor and Chair, USUHS; Kanter, M., MD, Medical Director, Quality & Clinical Analysis, Kaiser Permanente; Chase, A., BS, MS, Consultant, LLC, No Organization; York, G., Surgical Services Consultant - USAF Surgeon General, Air Force Medical Operations Agency; Rush, R., MD, Surgeon, Madigan Army Medical Center; Cordts, P., MD, Deputy Director for Healthcare Operations, Department of Defense B15 High Reliability and Robust Process Improvement
Learning Format: Lecture Track: Patient Safety High-reliability health care is now considered a realizable goal, but the question of how to achieve it remains. Robust Process Improvement (RPI) provides a high-reliability framework that enables customized solutions to serious problems insufficiently addressed by checklists. Instead of QI projects, RPI produces standard work for ongoing safety and quality gains. Participants will learn a new and more effective way to deliver results that for the next generation of best practices. After this presentation, participants will be able to:
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Differentiate between RPI and traditional approaches to health care quality improvement and understand how RPI produces new standard work to yield permanent safety and quality improvements
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Differentiate between the problems that can be addressed with checklists and the problems for which RPI is the best approach
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Identify why and how quality and safety problems vary among different health care settings and organizations and how to implement high-reliability solutions
Presenters: Shabot, M., MD, FACS, FCCM, FACMI, Executive Vice President/Chief Clinical Officer, Memorial Hermann; Chassin, M., MD, FACP, MPP, MPH, President and Chief Executive Officer, The Joint Commission
Created Date : 9/22/2016
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28th Annual National Forum on Quality Improvement in Health Care B16 Long-Term-Care Facilities as Arenas for Compassionate Quality Improvement Work
Learning Format: Lecture Track: Patient Safety Does your staff have the necessary personal information about their patients 24/7? Centering its care on compassion and rapid transfer of critical information, Norlandia Oppsalhjemmet, a nursing home in Oslo, extensively uses well-tested dialogue tools with relatives, including living wills, as well as huddleboard meetings for individualized care and risk reduction. This workshop will discuss the tools that have proven their value during seven years of systematic QI work while making work meaningful and joyful for the staff. After this presentation, participants will be able to:
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Identify QI methods that have proven helpful in a long-term care facility
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Understand how emphasizing the individuality of residents puts compassion into care
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Recognize the benefit of extensive dialogue with and preparation of relatives
Presenters: Ore, S., Nursing Home Physician, The Norwegian Medical Association; Bonite, K., Registered Nurse, Norlandia AS, avdeling Oppsalhjemmet B17 Reliable Diagnosis and Tracking in Primary Care
Learning Format: Case Study Track: Patient Safety Many primary care practices struggle to provide reliable systems for diagnosis and tracking patients and referrals. This session will review the impact of “hidden” human stressors on diagnosis; lessons from the HMS Academic Innovations Collaborative on creating effective, reliable closed-loop systems; and strategies that any organization can use to drive similar improvements. Discussion will include examples related to preventive screenings and presentation of red flag symptoms in diverse primary care settings. After this presentation, participants will be able to:
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Understand the range of human factors that interfere with and degrade diagnostic accuracy and timeliness
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Identify patient-centered processes to improve the tracking and follow-up of screening and diagnostic testing
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Identify specific changes that can be tested to create more reliable processes at their own organization
Presenters: Hunt, L., MEd, Director, Health Systems Transformation, Harvard Medical School Center for Primary Care; Cohen, D., Chief Medical Officer, Datix (USA) Inc; Graber, M., President, Society to Improve Diagnosis in Medicine
Created Date : 9/22/2016
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28th Annual National Forum on Quality Improvement in Health Care B18 Surgical Interventions in Birth: Global Perspectives
Learning Format: Rapid-Fire Sessions Track: Patient Safety While the WHO recommends a Cesarean section rate of 15%, many countries struggle with overuse, underuse, or misuse. This session will share how QI initiatives are being designed, tested, and implemented to determine right care, at the right time, in the right context. We will share design elements and current results from Brazil, the US, and India and support interaction to enhance learning of what is needed to improve maternal and neonatal health. After this presentation, participants will be able to:
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Understand the variation in nulliparous cesarean rates from a regional and provider perspective
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Discuss the influence of arbitrary targets on delivering the right care at the right time to patients
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Identify strategies for developing and adapting improvement methods in local contexts around the world
Presenters: Leavitt Gullo, S., RN, BSN, MS, Director, Institute for Healthcare Improvement; Borem, P., Director Projects Latin America, Institute for Healthcare Improvement; Mehndiratta, A., MBBS,DCH,DNB,MPH, Faculty, Institute for Healthcare Improvement; Barker, P., MBChB,MD, Senior Vice President, Institute for Healthcare Improvement B19 Are We Improving the Patient Experience?
Learning Format: Controversy Panel Track: Person- and Family-Centered Care Patient-centered care (PCC) is on everyone's priority list, and yet the word on the street about health system experiences remains predominantly negative. Is your work making a difference to the majority of patients coming through your doors? This expert panel will discuss the gaps and disconnects and explore practices that truly matter in the patient and family experience. This session will deliver a lively, informative discussion among people with passion and experience in PCC. After this presentation, participants will be able to:
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Examine the relationship between patient-centered care and patient experience
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Identify gaps in the improvement work being done in PCC and its actual effects on patients
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Share high-leverage tactics for transforming the experience of patients and their families
Presenters: Wolf, J., PhD, President, The Beryl Institute; Mullen, C., Doctoral Candidate/Associate Instructor, Indiana University Purdue University Indianapolis; Hayward, M., Lead, Patient and Family Engagement, Institute for Healthcare Improvement; Srisaneha, E., Project Manager, Southcentral Foundation; Andrews, D., Patient Advisor, Georgia Regents Medical Center
Created Date : 9/22/2016
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28th Annual National Forum on Quality Improvement in Health Care B20 What Matters to You? Using Co-design to Revolutionize Patient Experience
Learning Format: To Be Determined Track: Person- and Family-Centered Care In this interactive workshop, participants will use IHI’s Always Events framework to co-design an improvement effort to improve outcomes that matter to patients. Participants will complete prework to learn the Always Events framework and rules of radical redesign. Onsite, Sutter Health will share their journey using these frameworks to transform patient experience and promote wellbeing. The session will conclude with small group coaching focused on creating an Always Event for your organization. Come with an improvement idea in mind and get ready to roll up your sleeves and co-design! After this presentation, participants will be able to:
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Explore methods for determining what matters to patients, service users, and care partners.
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Describe the evolution of the Sutter Health Always Event designed to transform the patient experience and promote well being.
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Illustrate examples of adoption and spread of our Always Event across the Sutter Health continuum of care.
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Initiate an action plan to begin the steps to co-design an Always Event in your setting
Presenters: Gunther-Murphy, C., Executive Director, Institute for Healthcare Improvement; Mather, C., MA, Senior Project Manager, Institute for Healthcare Improvement; Suter, P., Clinical Director, Sutter Health; Hennessey, B., RN, BSN, MSN, Executive Director Sutter Center for Integrated Care, Sutter VNA and Hospice B21 Patients as Partners: New Ways to Design Care
Learning Format: Rapid-Fire Sessions Track: Person- and Family-Centered Care Hear firsthand from patients and staff about leading-edge practices and mindsets that are transforming care and experience. Gain insight on how to co-design with patients to improve performance and bring greater meaning, purpose, and value to your team and strategic priorities. Inspirational case studies will give you starter tools for applying design thinking and quality improvement to gather deep insights and accelerate learning and spread in your organization. After this presentation, participants will be able to:
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Describe leading-edge ways to partner with patients, families, and caregivers to design and improve care
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Understand the essential role of design thinking in accelerating learning and driving quality improvement
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Access tools, methods, and mindsets for the strategic priorities in their own initiatives to improve and innovate
Presenters: Neuwirth, E., PhD, Senior Director, Innovation Design, Kaiser Permanente's Care Management Institute; McCarthy, C., MPH/MBA, Director, Innovation Learning Network, Kaiser Permanente; Martinez, R., Patient Advisor, Kaiser Permanente South Sacramento; Harvey, P., RN, Sr. Vice President, Kaiser Permanente
Created Date : 9/22/2016
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28th Annual National Forum on Quality Improvement in Health Care B22 Stop Seeing the Patient, Start Seeing the Person
Learning Format: To Be Determined Track: Person- and Family-Centered Care In an ever-demanding clinical and technical environment, we are continuously challenged to find ways to truly connect with patients. Traditional perceptions are flipped when we ask patients and their families, "What matters to you?" Hear how a simple tool has transformed care and the power of real patient stories has led to the spread of "What Matters to Me" from pediatrics and the care of older people to wide use across the NHS in Scotland. After this presentation, participants will be able to:
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Describe the tools and techniques, inspired by real patient stories, that are required to implement genuinely person-centered care
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Develop their own approach to using "What Matters to Me" in patient-centered care by asking what matters, listening to what matters, and doing what matters
Presenters: Rodgers, J., n/a, No Organization B23 ACO, P4P, MACRA: From Acronyms to the Triple Aim
Learning Format: Rapid-Fire Sessions Track: Quality Cost and Value Participants in this session will learn the building blocks for creating a high-value, patient-centered, and affordable delivery system that maintains joy in work. Emory Healthcare Network leaders will present, in rapid-fire format, the key elements of their population management platform and offer important administrative, clinical, analytical, and value-related lessons. Participants will leave with a framework for developing their own value-based delivery platform. After this presentation, participants will be able to:
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Identify the necessary fundamentals for deploying a value-based care delivery model
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Understand the important elements of creating an effective population management platform
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Apply key administrative, clinical, operational, and data-related lessons in the pursuit of value
Presenters: Gitomer, R., MD, President & CQO, Emory Healthcare Network; Koch, K., Director of Value Management, Emory Healthcare; Galatas, T., Corporate Director, Emory Healthcare Network, Emory Healthcare; Landor, M., RN MSN CNS ANP-C, Manager of EHN Care Coordination, Emory Healthcare B24 Quality Improvement for Social Needs Interventions in Health Care
Learning Format: Rapid-Fire Sessions Track: Equity, Quality Cost and Value Health care delivery systems increasingly recognize that health is affected by social conditions outside hospital and clinic walls. This awareness has inspired efforts to systematically identify patients’ social needs and build linkages to "upstream" community resources. This session will focus on the growing opportunities to determine how to measure and enhance the efficiency, efficacy, and scalability of such services, featuring leading organizations that use QI to optimize patient and population health by proactively engaging partners and aligning with payers. After this presentation, participants will be able to:
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Define a role for hospitals, clinics, and health care providers in addressing “upstream” social needs
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Identify current knowledge gaps on how to best measure and enhance the efficiency, efficacy, and scalability of such services
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Describe how leading organizations identify and act on social needs in order to optimize patient and population health
Presenters: Kahn, R., MD MPH, Professor, Associate Chair for Community Health, Cincinnati Children's Hospital Medical Center; Goldstein, Z., Principal, Innovation, Health Leads; Beck, A., MD, MPH, Pediatrician, Cincinnati Children's Hospital Medical Center; Manchanda, R., MD MPH, Founder, HealthBegins, HealthBegins; Mossman, N., MPH, Program Mgr, Payment Reform/Social Determinants of Health, OCHIN B25 What Is a Patient's Chance of Survival from Sepsis in Your Organization?
Learning Format: Lecture Track: Quality Cost and Value Sepsis can have up to a 30% mortality rate if it goes undetected and is not treated rapidly. In this session, learn how one organization strove to achieve a 90% chance of survival from sepsis, or greater, for its patients across an entire health system, with the goal of ensuring that the chance of survival from sepsis would be 10% or less for anyone admitted to any hospital. After this presentation, participants will be able to:
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Define the elements of a clinical effectiveness program to decrease variation and improve sepsis care
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Understand where variance occurs in the treatment of sepsis and how to decrease it
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Describe the role of the sepsis nurse in early identification of sepsis, treatment, and standardization of sepsis care
Presenters: Alvarez, T., MSN, RN, CCRN-K, Executive Director, Performance Improvement, Providence St. Joseph Health; Vovan, A., MD, MBA, FCCM, Exec Med Dir Clinical Effectiveness, St Joseph Hoag Health; Myran, R., MSN, RN, PCCN, Sepsis Coordinator, HOAG MEMORIAL HOSPITAL PRESBYTERIAN; Jasper, E., Director, Performance Improvement, St Joseph Health System B26 A Systems Approach to the Opioid Crisis
Learning Format: Case Study Track: Triple Aim for Populations Even as significant resources are being channeled toward the opioid crisis (responsible for 28,647 deaths in 2014), it persists and worsens. We believe it is necessary to replace isolated efforts to intervene with a system approach across an entire community, coordinated between health care, law enforcement, and public health stakeholders. This session will describe IHI’s system approach to addressing the opioid crisis and highlight examples from communities that are reducing opioid-related morbidity and mortality. After this presentation, participants will be able to:
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Describe a system approach to addressing the opioid crisis, including the roles of different stakeholders
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Understand how communities have successfully deployed multiple strategies to reduce opioid-related morbidity and mortality
Presenters: Laderman, M., MSPH, Senior Research Associate, Institute for Healthcare Improvement; Martin, L., MSPH, Executive Director, Institute for Healthcare Improvement
Created Date : 9/22/2016
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28th Annual National Forum on Quality Improvement in Health Care B27 From Clinical to Social: Redefining What Counts as Health Care
Learning Format: Rapid-Fire Sessions Track: Equity, Triple Aim for Populations Until now, traditional health care has not addressed the social and environmental factors that account for 70% of health outcomes. From the recent release of the CMS Accountable Health Communities model to the imperative to better understand and treat the needs of their most complex populations, health systems are redefining what constitutes health care. This session will explore innovative tools to assess social needs and ways to leverage new and existing services in the housing, food, social isolation, and transportation arenas to augment clinical care. After this presentation, participants will be able to:
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Contextualize recent strong market signals around addressing patients' social needs in the broader shift toward value-based care models
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Discuss methods and tools to identify the factors getting between people and optimal outcomes and creative ways to address them
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Apply lessons and strategies learned to their own organization’s efforts
Presenters: Englert, R., Sr. Business Leader, Community Health Innovation Programs, CareOregon; Perla, R., President, Health Leads; Moore, L., MD, Senior Medical Director, 3M Health Information Systems, Inc.; Lewis, N., MS, Executive Director, Institute for Healthcare Improvement B28 Enhanced Recovery After Colorectal Surgery
Learning Format: Case Study Track: Triple Aim for Populations Our community medical center implemented an Enhanced Recovery After Surgery (ERAS) protocol aimed at decreasing surgical stress to colorectal patients and reducing hospital length of stay and morbidity. The ERAS protocol was based on multidisciplinary input from surgeons, nurses, pharmacists, anesthesiologists, and resident surgeons. With the ERAS program, patients have experienced a quicker advancement of diet with reduced analgesia usage and shorter length of stay and without a significant difference in morbidity or mortality. After this presentation, participants will be able to:
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Implement a perioperative platform for a standardized, evidence-based ERAS protocol for all patients undergoing elective colorectal resections
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Assess whether successful adoption of an ERAS protocol reduces length of stay and postoperative complications after elective surgery
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Compare outcomes reported in the literature with our institutional outcomes with an ERAS protocol
Presenters: Shapiro, S., Surgeon, Gundersen Health System; Bray, M., Resident Surgeon, Gundersen Health System
Created Date : 9/22/2016
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28th Annual National Forum on Quality Improvement in Health Care B29 How to Successfully Implement the Triple Aim in a Community
Learning Format: Case Study Track: Triple Aim for Populations Pueblo's six-year pursuit of the Triple Aim has achieved remarkable results, lowering teen pregnancy rates by 40% and preventable elderly readmissions by 50%. Even with these successes, however, there are many obstacles to overcome to fully implement the Triple Aim in Pueblo. We will share the plan that we have used so that other communities can copy the formula and avoid our mistakes in achieving the Triple Aim for a community. After this presentation, participants will be able to:
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Identify the major components of successful implementation of the Triple Aim in a community as well as the avoidable pitfalls
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Create action steps for their own community to start or advance their thinking on how to implement the Triple Aim for their population
Presenters: Whittington, J., MD, IHI Lead Faculty, Triple Aim Initiative, Institute for Healthcare Improvement; Guy, M., MPA, Executive Director, Pueblo Triple Aim Corporation B30 Population Health in the Military Health System
Learning Format: To Be Determined Track: Triple Aim for Populations The Military Health System (MHS) has been engaged in population health for almost two decades. This presentation will cover how the program has managed to serve the military population this long by being scalable, extensible, and flexible. The session will include quality measurement, registries, predictive analytics, metadata tagging, forecasting, and real-time clinical decision support for high-risk populations. After this presentation, participants will be able to:
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Discuss the MHS journey with population health and the role of enterprise-mindedness in encouraging innovation and flexibility for medical management
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Describe how predictive analytics as a platform provides clear insight into improvement opportunities for the coordination and delivery of health care
Presenters: Carnahan, D., MD, MSCE, Enterprise Intelligence Branch Chief, DHA / Gov
Tuesday, December 6: Receptions and Meals 12:40 PM - 1:20 PM LNLS Lunch and Learn: Free From Harm: Creating Total Systems Safety
Learning Format: Buzz Session Track: Patient Safety
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28th Annual National Forum on Quality Improvement in Health Care Join Dr. Tejal Gandhi, MD, MPH, CPPS, President and CEO of the National Patient Safety Foundation and learn about NPSF’s new report, Free from Harm: Accelerating Patient Safety Improvement Fifteen Years after To Err Is Human, and the future of patient safety. Free from Harm considers the current state of patient safety and provides a roadmap for advancing progress. A key finding of the report is that, despite efforts, we have failed to make substantial, measurable, system-wide strides in improving patient safety. Advancing patient safety in a meaningful way will require an overarching shift from reactive, piecemeal interventions to a total systems approach to safety in which safety is uniformly applied across the entire health care system. During this session, Dr. Gandhi will discuss what is needed to achieve total systems safety and improve patient safety in coming years. Presenters: Gandhi, T., MD MPH, President, National Patient Safety Foundation LNLE Lunch and Learn: Promoting Equity, Quality, and Access within the Specialty Care Setting
Learning Format: None Track: Equity In June 2016, the Bristol-Myers Squibb Foundation and FSG published a new equity resource for the specialty care field— Breaking the Barriers to Specialty Care: Practical Ideas to Improve Health Equity and Reduce Cost – as part of the Foundation’s Specialty Care for Vulnerable Populations grants and partnership program. This modular series of five issue briefs was developed as a tool for education, engagement and mobilization of the specialty care providers and healthcare institutions in health equity work including through quality improvement. Presenters: Doykos, P., PhD, Director, BMS Foundation, Bristol-Myers Squibb Foundation; Smith, L., Managing Director, FSG
Tuesday, December 6: Workshop C 1:30 PM - 2:45 PM SW5 Storyboard Walkaround: Students Present their Improvement Projects
Learning Format: Storyboard Walkaround Students can play a critical role improving quality, both during their training and in their future careers. In this session, IHI Open School faculty and academic advisors will lead a discussion with four students whose storyboards were selected as examples of high-impact student work. Learn how you can engage students and trainees in quality improvement and invest in a new generation of change agents. C1 Disruptive Innovations: Self-Care and Health Equity
Learning Format: Lecture Track: Equity Outpatient parenteral antimicrobial therapy (OPAT) is accepted as a safe and effective way for medically stable patients to complete intravenous antibiotics in an outpatient setting. Many uninsured patients cannot afford OPAT, however, and do not have this option, and safety-net hospitals are often burdened with long hospitalizations and do not have beds for patients requiring more intensive services. In this session, participants will learn about a program that has safely shifted the care of uninsured patients to at-home selfadministration of IV antibiotics. After this presentation, participants will be able to:
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Identify the principles of self-care in the OPAT model
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Identify the role of health literacy and the teach back method in successful self-care initiatives
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Develop multidisciplinary models of care delivery to address the needs of underserved populations
Presenters: Bhavan, K., Assistant Professor, Parkland Health and Hospital System; Agrawal, D., MD, MPH, MBA, Associate Professor, University of Texas Southwestern C2 Building QI Capacity: Delivering Results at Scale
Learning Format: Buzz Session Track: Improvement Capability Improvement science delivers results at scale in many systems, including Kaiser Permanente, Cincinnati Children’s Hospital, and Scotland’s public services, which have developed advanced approaches to building the quality improvement skills of practitioners at all levels of their systems. Participants will achieve whole system knowledge with a shared language for improvement and consider how these approaches for capacity building enable work that goes beyond health care improvement, integrating innovation with improvement and focusing on improving community health. After this presentation, participants will be able to:
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Identify common challenges across systems related to building capacity and capability to achieve results at scale
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Consider opportunities to adopt and adapt capacity-building approaches to meet the needs of multiprofessional teams working to improve community health
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Understand approaches to integrating innovation and improvement and effectively involving member voices in efforts to improve health experience and outcomes
Presenters: Hannah, S., Head of Children & Young People Improvement Collaborative, Scottish Government; Kotagal, U., MBBS, MSc, Senior Executive Leader, Population and Community Health, Cincinnati Children's Hospital Medical Center; Schilling, L., RN, MPH, National Vice President, Healthcare Performance Improvement, Kaiser Permanente; Leitch, J., National Clinical Director, Scottish Government Health Department C3 National Quality Forum Framework for Home- and Community-Based Services
Learning Format: Lecture Track: Equity, Improvement Capability The US spends $75 billion each year on home- and community-based services (HCBS), which are vital to promoting independence and wellness. This is a critical time to make progress toward building a high-quality HCBS system that supports older adults and people with disabilities in achieving independence, good health, and quality of life. This session will unveil the National Quality Forum’s HCBS framework, opening the discussion for how HCBS quality measurement will factor into care delivery and reimbursement. After this presentation, participants will be able to:
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Describe the creation of the HCBS framework and define high-quality HCBS
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Orient their organization to the HCBS domains of measurement
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Discuss the implications of the HCBS framework for reimbursement and care delivery
Presenters: Ostrovsky, A., MD, CEO, Care at Hand; Anderson, A., Project Manager, National Quality Forum C4 Formal Debate: Patients are best cared for with virtual, on-demand medicine
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28th Annual National Forum on Quality Improvement in Health Care Learning Format: Controversy Panel Presenters: Meisinger, K., MD, Medical Director, Cambridge Health Alliance; Swamy, L., MD, MBA, Resident, Boston Medical Center; Worsham, C., MD, Chief Medical Resident & VA Chief Resident in Quality/Safety, Boston Medical Center GME Program C5 Tearing Down the Barriers to Continuous Improvement
Learning Format: Buzz Session Do you want accelerated change, breakthrough results, and sustained gains? In this fun session, we will share our deployment and results and you will work in groups to assess your own improvement culture across eight dimensions, identify your barriers, learn cross-functional management tools and behaviors to eliminate those barriers, and leave with a plan for next steps on your improvement journey. Attend as a team if you can, but this session will also be great for individuals. After this presentation, participants will be able to:
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Assess their improvement culture on multiple continuums
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Identify methods for removing barriers to continuous improvement
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Envision new structures for leadership across silos
Presenters: Weddle, L., Regional Director System Improvement, Providence Health and Services; Bensen, C., n/a, No Organization C6 The Science of Flow and Design: The Emergency Department Super Track
Learning Format: Lecture Track: Improvement Capability Health care organizations are seeking new approaches to the evolving needs of emergency departments (EDs). Northwell Health has implemented a split flow model in several existing EDs with promising results. Now, in partnership with CannonDesign, the organization has designed two new EDs with a goal of optimizing efficiency for all patients by utilizing a split flow/super track care model. This presentation will highlight the methodology, flow strategies, and the design decisions implemented by our interdisciplinary team. After this presentation, participants will be able to:
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Articulate the value of a super track as an effective LEAN process redesign strategy
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Examine the implications of a super track for the planning and design of emergency departments
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Formulate strategies that enhance design and medical team collaboration for better operational and clinical outcomes
Presenters: Masters, R., Principal, CannonDesign; D'Angelo, J., MD FACEP, Executive Director Senior Vice President, Emergency Medicine, Northwell Health
Created Date : 9/22/2016
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28th Annual National Forum on Quality Improvement in Health Care C7 High Engagement and Low Burnout: Solutions for Your Workplace
Learning Format: Rapid-Fire Sessions A disengaged clinician raises the chances of poor quality, poor patient experience, and even harm to the patient, and we know that 54% of physicians report symptoms of burnout. Solutions lie in the sweet spot where increasing engagement and satisfaction also reduce burnout. Participants' own challenges will be the basis for learning practical and high-leverage solutions, including effective waste and inefficiency reduction. We will also present the key supportive leadership behaviors. After this presentation, participants will be able to:
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Describe the human and organizational costs of disengagement and burnout
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Identify at least three changes in management and leadership that solve both burnout and disengagement
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Create a plan to institute these changes in the next six months in their own setting
Presenters: Swensen, S., MD, MMM, FACR, Medical Director, Leadership & Organization Development, Mayo Clinic; Barker, P., MBChB,MD, Senior Vice President, Institute for Healthcare Improvement; DeChant, P., MD, MBA, Senior Advisor, Simpler Consulting; Shannon, D., MD, MPH, Health care writer, Shannon Healthcare Communications C8 If You Build It, They Will Come: How to Make a Better Resident Experience
Learning Format: Lecture Track: Joy in Work With value-based reimbursement coming in fast, we need better primary care now. The next generation of care needs doctors who are ready to bring authentic improvement to their resident clinics and beyond. In this session, we will present examples and lessons we have learned while researching high-functioning primary care residency clinics nationally, running a four-year collaborative to drive improvement in 24 primary care resident clinics, and providing care at the front line of a leading residency program. After this presentation, participants will be able to:
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Describe how promoting a “clinic first” residency design and other key concepts can create exceptional resident experience in primary care
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Access specific examples of resident practices improving resident experience in clinics
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Develop specific strategies to improve resident experience at their own practice
Presenters: Hunt, L., MEd, Director, Health Systems Transformation, Harvard Medical School Center for Primary Care; Gupta, R., MD, Assistant Professor of Medicine, University of California, San Francisco; Sawin, G., MD, Program Director, Cambridge Health Alliance; Rittner, S., MD, MD, Cambridge Health Alliance
Created Date : 9/22/2016
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28th Annual National Forum on Quality Improvement in Health Care C9 Managing for Sustainable Innovation
Learning Format: Case Study Track: Leadership Health care delivery systems are increasingly seeking to develop their own innovation function to support the generation and implementation of new ideas. During this session, participants will work together to design, develop, and understand a reliable innovation management structure for their own organization’s current and future challenges. Participants will be guided on how to consider the best management system for their innovation function and how to balance it with their ongoing performance engine. After this presentation, participants will be able to:
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Develop management strategies for the innovation function in their organization
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Articulate the difference between managing innovation and managing ongoing work
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Create a baseline plan to implement an innovation management system for a strategic initiative
Presenters: Mate, K., MD, Chief Innovation & Education Officer, Institute for Healthcare Improvement; Martin, L., MSPH, Executive Director, Institute for Healthcare Improvement C10 Strategies to Reduce Readmissions, Sepsis, and Health-Care Associated Infections
Learning Format: Rapid-Fire Sessions Track: Leadership Leveraging the leadership of nurses from all levels of our organization, Veterans Affairs Palo Alto Health Care System has successfully reduced readmissions by 30%, decreased sepsis mortality by 12%, and demonstrated improvement in health-care associated infections (HAIs). Frontline nurses provide invaluable perspective on the challenges and barriers to improving critical clinical processes. Learn how to utilize nursing expertise, prepare nurses with leadership skills, provide resources, and foster an environment of inquiry to drive clinical outcomes. After this presentation, participants will be able to:
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Describe proven strategies for leveraging nurses to improve rates of readmission, sepsis, and HAI
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Understand the potential impact of direct care nurse leadership
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Identify focus areas at their facility in which nurse-driven improvement could have a positive impact on clinical outcomes
Presenters: Renfro, D., MS, RN, Chief Nurse Specialty & Hospital Based Services, Veterans Health Care Administration C11 An Implementation Framework for Patient Safety in Ambulatory Care
Learning Format: Lecture Track: Patient Safety Northwell and IHI have been working to co-design and test methods for applying the Patient Safety Framework in multiple ambulatory settings. Join us to learn, from the experience of frontline teams, how to identify, prioritize, and improve on the safety concerns that really matter in ambulatory care. Participants will learn about the Framework for Clinical Excellence and what it takes to deliver safe care reliably. After this presentation, participants will be able to:
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Understand the safety issues and challenges in ambulatory care settings
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Develop strategies to begin the conversation that will start them on their own journey in patient safety
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Describe a framework that provides a sustainable approach to patient safety
Presenters: Lenoci-Edwards, J., RN, MPH, Safety Focus Area Owner, Institute for Healthcare Improvement; Brooks, A., Client Portfolio Director Patient Safety, Institute for Healthcare Improvement; Braunstein, R., Executive Director, Manhattan Eye, Ear, and Throat Hospital C12 Beyond Projects: How to Create a System of Safety
Learning Format: To Be Determined Track: Patient Safety When we work on creating safer patient care, we design and complete a series of projects with necessary components that can be described, created, and assessed. But does the sum total of these projects, even when successful, actually create a system of safer care in which patients are less likely to suffer harm? In this session, we will present a framework that details the components that must be present in any effort to create safer care systems. After this presentation, participants will be able to:
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Distinguish between safety projects and a system of safety
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Define the components of a system of safety
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Differentiate between continuous learning systems and a culture of safety at both organizational and unit levels
Presenters: Haraden, C., PhD, Vice President, Institute for Healthcare Improvement C13 Improving Safety in Brazil: The Salus Vitae Story
Learning Format: Case Study Track: Patient Safety Infections associated with health care are a preventable complication and represent a major threat to patient safety, especially in low- and middle-income countries. A Brazilian health system recently launched the Salus Vitae Program, an ICU collaborative built in partnership with IHI, to improve patient safety through leadership, innovation, and capacity building. This session will review the key success factors from the Salus Vitae experience and discuss their relevance for improvement initiatives in other countries. After this presentation, participants will be able to:
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Identify the key success factors in the implementation of a collaborative aimed at reducing hospitalacquired infections and improving patient safety in Brazil
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Understand how to build collaborative learning and innovation to promote best practices to improve patient safety
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Recognize the importance of leadership in improving patient safety at a systems level
Presenters: Sardenberg, C., MD, MsC, MBA, Corporate Director, Quality and Patient Safety, ACSC Associação Congregação de Santa Catarina; Lajolo, C., MD,MBA,MPH, Corporate Medical Manager for Quality and Patient Safety, ACSC - Associação Congregação de Santa Catarina; Rooney, K., MBChB FRCA FFICM FRCP, Professor of Care Improvement, NHS Scotland; Luther, K., RN, MPM, Vice President, Institute for Healthcare Improvement; Borem, P., Director Projects Latin America, Institute for Healthcare Improvement
Created Date : 9/22/2016
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28th Annual National Forum on Quality Improvement in Health Care C14 Reducing Delirium: Improving Care Along a Continuum
Learning Format: Lecture Track: Patient Safety Gundersen Health System’s multidisciplinary team of providers, pharmacists, therapists, nurses, phlebotomists, and pre-admissions staff devised a systematic approach to recognizing and reducing the risk of delirium for patients in the hospital. We will share our delirium improvement journey, providing details on how we leveraged technology, screening tools, education, huddles, and collaboration to improve patient care and reduce the risk of delirium. Our future journey will expand the work across all transitions of care and post-discharge. After this presentation, participants will be able to:
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Conceptualize how delirium crosses the continuum of care for an integrated health system
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Understand how to assemble a multidisciplinary team to create system change
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Describe assessment methodology, including tools and their limitations, to identify the patients at risk for delirium
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Formulate an action plan to implement delirium prevention and treatment strategies
Presenters: Mulrennan, B., Hospitalist, Gundersen Health System; Boisen, H., RN-Project Manager, Gundersen Health System; Heimer, D., RN, Nurse Educator, Gundersen Health System; Oneill, M., Executive Director, Gundersen Health System C15 Risky Talk: Conversations Advancing Safety Culture
Learning Format: Buzz Session Track: Patient Safety When you see someone inadvertently putting patients at risk, you should speak up—or maybe not? In a "safety first" culture, you would speak up, but developing that culture is hard work and requires balancing the quality of interprofessional relationships against your ability to drive culture change. This session will engage participants in scenarios that challenge their reactions, with the goal of learning some ways in which focusing on safety can strengthen relationships. After this presentation, participants will be able to:
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Build their personal credibility by speaking up
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Develop their "threshold" intuition—when to voice a concern and when to stay quiet
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Protect their professional relationships by speaking about the process
Presenters: Kenefick, B., Director, Lean Process Improvement, University Health Network; Zee, J., BScPT, Clinical Director, TRI Brain and Spinal
Created Date : 9/22/2016
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28th Annual National Forum on Quality Improvement in Health Care C16 Safety in Numbers: Overcoming Barriers to Event Reporting
Learning Format: Rapid-Fire Sessions Track: Patient Safety A robust adverse event reporting system is an important component of high-reliability organizations. Children’s National established the corporate goal of doubling safety event reporting and improving the culture around safety event management. In this session, participants will learn about the strategies employed by a multidisciplinary team to engage employees using Just Culture to promote a safe reporting environment while developing a system to provide tactics such as closed-loop communication and tracking of adverse events. After this presentation, participants will be able to:
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Address common barriers to safety event reporting
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Develop strategies to apply Just Culture principles in a hospital environment and integrate a follow-up process to engage employees so that reporting makes a difference
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Develop ways to improve the usefulness of their reporting system to provide more meaningful information
Presenters: Patrick, D., PharmD, Medication Safety Coordinator, Children's National Medical Center; Sigman, L., MD, JD, Physician, Risk Manager, Children's National Medical Center; Kalburgi, S., DO, MSHS, Pediatric Hospitalist, Children's National Medical Center; Freiburg, D., MS, BSN, NE-BC, Director of Medical Nursing, Children's National Medical Center; Shah, R., MD, MBA, Chief Quality and Safety Officer, Children's National Medical Center C17 Understanding Top Health IT Safety Hazards
Learning Format: Lecture Track: Patient Safety Since 2014 the Partnership for Health IT Patient Safety has brought together a multi-stakeholder collaborative of health care providers, health IT developers, safety experts, clinical users, professional societies, and others, including IHI, with the goal of making care safer together. In this lively discussion on the latest developments in this vitally important area, participants will find out how to accelerate safety science to IT and informatics and will benefit from interactions with peers from around the country. After this presentation, participants will be able to:
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Identify the top safety events and hazards reported to the Partnership for Health IT Patient Safety
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Apply multi-stakeholder-generated health IT safe practices for patient identification
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Define ways to establish a culture of safety in which adverse events that might injure patients and damage organizational reputation are prevented
Presenters: Solomon, R., EVP and General Counsel, ECRI Institute; Sengstack, P., Chief Nursing Informatics Officer, Bon Secours Health System; Marella, W., MBA, MMI, Executive Director, PSO Operations and Analytics, ECRI Institute
Created Date : 9/22/2016
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28th Annual National Forum on Quality Improvement in Health Care C18 Around the World in Mental Health Improvement
Learning Format: Rapid-Fire Sessions Track: Person- and Family-Centered Care This session will describe the work taking place around the world to tackle complex problems in mental (behavioral) health through the application of quality improvement methods. Case studies will be drawn from the East London NHS Foundation Trust, the Scottish Patient Safety Program, and the Danish Society for Patient Safety. The session will identify the opportunities and challenges of applying QI methods within this setting. After this presentation, participants will be able to:
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Develop a consensus on the utility of quality improvement methods in tackling complex mental health quality issues
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Identify key elements in applying quality improvement to mental health services
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Create ideas on how to engage and involve patients and professionals to improve mental health services
Presenters: Shah, A., Associate Medical Director (QI) & Consultant forensic psych, East London NHS Foundation Trust (ELFT); Rischel, V., RN, BA, MHSc, Programme Director, Danish Society for Patient Safety; Hall, D., MBChb FRCPsych, Consultant Psychiatrist, NHS Dumfries and Galloway C19 Mayo Clinic's Empathic Communication Training
Learning Format: Buzz Session Track: Person- and Family-Centered Care This workshop will give an inside look at efforts to improve the patient and family experience at Mayo Clinic. Over the past two years, Mayo’s Office of Patient Experience has developed an interactive training program to assist staff with responding to challenging patient interactions by using empathic communication. During this interactive workshop, we will highlight some of the communication strategies taught in Mayo Clinic’s Empathic Communication Training Program. After this presentation, participants will be able to:
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Discuss the construction and implementation of a data-driven, empathy-based training program to improve clinical outcomes and patient/employee satisfaction
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Identify specific empathic communication strategies that can be applied in challenging patient scenarios to enhance the patient experience
Presenters: Ence, D., MHSA, Administrative Fellow, Mayo Clinic; Stevens, S., Patient Experience St. Advisor, Mayo Clinic C20 Rethinking Quiet at Night
Learning Format: Buzz Session Track: Person- and Family-Centered Care Many organizations struggle with the HCAHPS Quiet at Night measure. However, by reframing the problem in a person-centered way, organizations can make progress on supporting sleep and healing for patients. Those participating in this session will hear a theory of how to reframe the problem and how one organization made progress by implementing the theory. After this presentation, participants will be able to:
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Describe a new theory to address the HCAHPS Quiet at Night measure
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List the methods used by one organization to improve patient sleep and healing
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Develop an action plan to implement the Quiet at Night measure in their own organization
Presenters: Gunther-Murphy, C., Executive Director, Institute for Healthcare Improvement C21 Valuing “What Matters” Through Advanced Illness Conversations
Learning Format: Simulation Encounter Track: Person- and Family-Centered Care Do you reliably receive, record, and respect information about what matters to patients with advanced illness? Do you optimize the goals of care conversations through effective education for providers? In this session, you will glean lessons from the pioneering Conversation Ready work at IHI, learn about the Northwell Health Goals of Care Conversation Education Program® (GoCCEP™), and participate in a standardized patient simulation using a goals of care conversation technique to understand “what matters to you?” in your patients’ lives. After this presentation, participants will be able to:
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Identify the principles and key changes of being Conversation Ready
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Conduct goals of care conversations using a GoCCEP™ technique
Presenters: McCutcheon Adams, K., MSW, LICSW, Director, Institute for Healthcare Improvement; Friedman, M., DNP, MPA, RN, BC, CCRN, CNN, CHSE, Director of Clinical Initiatives, Northwell Health; Attivissimo, L., MD FACP FAAHPM HMDC, Senior Medical Director Hospice Care Network, Northwell Health; Walerstein, S., MD MACP, Associate Chief Medical Officer, Northwell Health C22 Accelerating Financial Returns with Three Behavior-Changing Toolkits
Learning Format: Lecture Track: Health Plans & Insurers Advancing Improv Even after we implement project management, robust clinical design, and Lean thinking, population health management financial returns often remain elusive. How do we change the personal behaviors of stakeholders, accelerate the pace of change, shape the thinking of our co-leaders and our staff, create change spark-plugs throughout our organizations, and make small changes take hold to create large returns? In this session, participants will learn three frameworks to scale trust across partners and stakeholders, multiply their impact, and preserve preexisting impacts. After this presentation, participants will be able to:
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Shape relationships in their own ecosystem to shift from skepticism to trust and action
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Plan to multiply their own impacts
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Prioritize their change agents to preserve impact
Presenters: Earley Toscano, C., MBA, Executive Director, ACO Clinical Transformation, Northeast, Aetna Accountable Care Solutions
Created Date : 9/22/2016
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28th Annual National Forum on Quality Improvement in Health Care C23 Choosing Wisely: Inspiring Action to Reduce Overuse
Learning Format: Rapid-Fire Sessions Track: Quality Cost and Value The Choosing Wisely campaign—which seeks to stimulate conversations between clinicians and patients about avoiding unnecessary care—is inspiring real-world system and behavior change in communities across the country. In this session, physicians and local leaders who are spearheading these efforts will share the implementation strategies that have worked for them in raising awareness and reducing overuse, as well as the challenges and barriers they have had to overcome. After this presentation, participants will be able to:
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Identify the ways in which Choosing Wisely could support a campaign to reduce overuse at their organization
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Discuss the ways in which Choosing Wisely increases awareness of the importance of overuse in their own state and community
Presenters: Martinson, J., MS, Director, Clinical Education, Washington State Medical Association; Stinnett, J., Hospitalist, Central Vermont Medical Center; Yarbrough, P., Physician, University of Utah; Slate Vitcavage, K., MS, Project Manager, Maine Quality Counts; Rand, K., Program Manager, ABIM Foundation C24 New Math: Taking on Overdiagnosis Waste and Harm
Learning Format: Flipped Classroom Track: Quality Cost and Value This session will discuss the “new math” needed to reduce overdiagnosis, overtreatment, harm, and the billions of dollars spent on wasted resources. We will focus on absolute risk reduction, the numbers needed to treat (NNT) patients without harm, patient-oriented endpoints that matter, publication bias, and advocacy. Participants will leverage key learnings from MemorialCare and their own experience to formulate a strategic initiative that advances this issue in support of the Triple Aim and responsible stewardship for our future. After this presentation, participants will be able to:
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Understand the difference between absolute and relative risk reduction and the numbers needed to treat or harm, as well as the relationship between NNT and value versus waste
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Describe the impact of publication bias on evidence-based medicine evaluations
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Identify clinical decision support tools to alert practitioners to overdiagnosis and overtreatment and develop a strategic focus and tools to reduce resulting harm and waste
Presenters: MacFie, H., PharmD, FABC, Chief Transformation Officer, MemorialCare Medical Centers; Leo, J., MD, Medical Director of Best Practice and Clinical Outcomes, Memorial Health Systems
Created Date : 9/22/2016
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28th Annual National Forum on Quality Improvement in Health Care C25 Supporting Policy to Improve Health Care Quality
Learning Format: Case Study Track: Leadership, Quality Cost and Value Efforts to improve health care quality should be supported by government policy. This session will examine how county-, state-, and national-level government could support and improve health care quality through a systematic and evidence-based approach. An example of such an approach—a conceptual taxonomy of quality-enhancing initiatives developed for the NHS in England—will be discussed, and we will explore the adaptation and implementation of the taxonomy for the American context. After this presentation, participants will be able to:
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Understand how the evidence for quality-enhancing initiatives has been categorized and compiled for the NHS in England
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Discuss how a taxonomy of quality-enhancing initiatives could be a useful tool for national, state, and local policymakers in the United States
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Identify ways to increase the value of policymaking by making it more evidence-based and therefore more likely to have a real effect on quality
Presenters: Leatherman, S., Professor, University of North Carolina (UNC) Health System; Martin, S., student, Harvard Medical School; Molloy, A., MB BCh BAO BA MRCPI MRCPUK DTM&H DipHIV, National Medical Director's Clinical Fellow, National Institute for Health and Clinical Excellence C26 A Population Approach to Maternal Health
Learning Format: Case Study Track: Triple Aim for Populations Few states, communities, or health systems have developed a comprehensive approach to improving care and reducing costs for pregnant women, including a coordinated system to address pregnancy intention and reproductive choice, substance use in pregnancy, and other social determinants of poor health outcomes. We will share the results of IHI’s population approach to reducing disparities in birth outcomes, featuring case examples from two promising models of care: Project Nurture in Oregon and the Dartmouth Hitchcock Perinatal Addiction Treatment Program. After this presentation, participants will be able to:
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Understand the key elements of a population health management model to improve perinatal care, especially for low-income women in under-resourced communities
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Describe the key elements of two programs designed to integrate care for pregnant women with substance use treatment
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Discuss early results of an initiative to improve birth outcomes in a community
Presenters: Bihrle Johnson, M., MPH, Director, Innovation, Institute for Healthcare Improvement; Pickard, L., Fellow, Institute for Healthcare Improvement; Goodman, D., Instructor in Ob/Gyn; Geisel School of Medicine at Dartmout, Dartmouth Medical School; Bellanca, H., Associate Medical Director, Health Share of Oregon
Created Date : 9/22/2016
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28th Annual National Forum on Quality Improvement in Health Care C27 An Oral Health Integration Framework and Toolkit
Learning Format: Lecture Track: Triple Aim for Populations Tooth decay and periodontal disease are common preventable chronic infections. Is your primary care practice prepared to expand oral health access by screening for, recognizing, and responding to these conditions? In this session, we will present a five-step framework for fitting oral health into a busy ambulatory practice, along with project management tools, educational resources, workflow strategies, population reporting techniques, and success stories from 19 delivery systems that put the mouth back in the body. After this presentation, participants will be able to:
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Understand the Oral Health Delivery Framework and what can be done in the primary care setting to improve oral health
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Identify challenges and solutions to implementation of the framework in diverse practice settings
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Understand the data and tools developed from primary care field-testing sites and take lessons from their experiences back to their organization
Presenters: Hummel, J., MD, MPH, Medical Director for Clinical Informatics, Qualis Health C28 Food, Heat, Housing: A Path to Addressing Social Needs
Learning Format: Buzz Session Track: Equity, Triple Aim for Populations What does it take for a health system to address patients’ unmet social needs? The question is more critical today than ever before—and a large group of health care systems have come together to answer it. Led by industry pioneers in driving systemic change, this interactive session will unveil the first roadmap designed to put health care systems on the path to addressing patients’ social needs as a standard part of quality care. After this presentation, participants will be able to:
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Share the key milestones for organizations on the path to meaningfully addressing patients’ unmet social needs
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Discuss the barriers that health systems face in implementing programs to address their patients’ social needs in care delivery processes
Presenters: Thompson, J., MD, Executive Advisor, Chief Executive Officer Emeritus, Gundersen Health System; Solomon, L., Ph.D., M.P.P., Vice President, Community Health, Kaiser Permanente C29 Population Management in the Safety Net
Learning Format: Buzz Session Track: Triple Aim for Populations In a rapidly changing delivery and payment environment, safety net organizations are under increasing pressure to deliver cost-effective care resulting in better outcomes and patient experiences. In this session, participants will learn how several safety net organizations have applied learnings from a three-month virtual program on population management to put themselves on a pathway from panel management to population health and accelerate their journey towards value-based care for entire populations. After this presentation, participants will be able to:
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List the core components of a population management framework for a safety net organization
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Describe how safety net organizations have used that framework and QI tools to accelerate their population management efforts
Presenters: Duong, T., MS, Project Manager, Institute for Healthcare Improvement C30 Psychiatric Emergencies: A Continuum of Solutions
Learning Format: Rapid-Fire Sessions Track: Triple Aim for Populations Health systems, particularly emergency departments, are increasingly challenged to care for patients with behavioral health needs, often without adequate expertise or support. The result is the familiar "revolving door"—emergency care and brief hospitalizations that consume large resources with uncertain results. Finding the right solution depends on many factors, such as organizational competencies, community resources, and state/local financing structures. This session will use three case studies to illustrate a continuum of possible solutions and introduce a common framework for measuring effectiveness. After this presentation, participants will be able to:
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Describe the challenges that emergency departments face in caring for patients with behavioral health needs
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Compare different approaches to addressing psychiatric emergencies in health care and community settings
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Understand how to reconfigure their current resources to reduce the number of psychiatric emergencies in the first place
Presenters: Balfour, C., VP for Clinical Innovation & Quality, ConnectionsAZ; Tucker, W., Clinical Professor of Psychiatry, Columbia Presbyterian Medical Center; Laderman, M., MSPH, Senior Research Associate, Institute for Healthcare Improvement; Santopietro, J., Chief Clinical Officer, Behavioral Health, Carolinas Healthcare System CFree Workshop C Free Time
Tuesday, December 6: Keynotes 8:00 AM - 9:00 AM K1 Captain Scott Kelly
Learning Format: Lecture
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28th Annual National Forum on Quality Improvement in Health Care Captain Scott Kelly Back from his historic record-breaking Year In Space, NASA astronaut Captain Scott Kelly has laid the groundwork for the future of space travel and exploration, and continues to garner media exposure like no other pioneer of our time. From the cover of TIME to live interviews on TODAY to features in Forbes and on CNN to a Twitter following that is rapidly approaching 1 million, the world remains in awe as we celebrate a hero’s return to the planet that is home, from an adventure that is extraordinary. With life lessons and personal stories that reveal unique and valuable advice on pushing one’s own limits, to insight on the leadership and teamwork required in such demanding conditions, and the challenges—such as long term deprivation from loved ones and Planet Earth—Kelly reflects on the choices and life events that paved his journey’s path and brings audiences to the edge of their seats as he delivers a truly one-of-a-kind experience. An astronaut since 1996, Kelly’s achievements over his illustrious 20-year career with NASA earned him the coveted position as America’s first year-round astronaut. On his historic mission that spanned from March 2015 to March 2016, Kelly and Russian cosmonaut Mikhail Kornienko conducted experiments, reconfigured station modules, and captivated the world with live interviews and never-seen-before photos from the International Space Station. The historic mission also included NASA’s groundbreaking Twins Study, in which Kelly’s identical twin brother, retired NASA astronaut Captain Mark Kelly served on the ground as a control model in an unprecedented experiment to understand how space affects the human body. Presenters: Kelly, S., Astronaut, NASA
3:15 PM - 4:15 PM K2 Abraham Verghese, MD and Derek Feeley
Learning Format: Lecture Dr. Abraham Verghese is a nationally bestselling author and a prominent voice in medicine with a uniquely humanistic view of the future of healthcare. His memoirs and novels on medical themes have sold millions of copies, topped bestseller lists, and earned major movie deals, while his New York Times articles arguing for greater focus on the physical patient have made waves in the medical community. His warmth and vision as well as his world-class gifts as a storyteller make him a powerful speaker both to healthcare professionals and the patient in all of us. Abraham sees a future for healthcare which marries technological innovation with the traditional doctorpatient relationship. He has a deep understanding of the new tools being placed in doctors’ and patient’s hands, but he also has a deep faith in the human hand itself as one of the most powerful tools in a doctor’s kit. He grounds his vision of technological progress in a humanistic commitment to listening to the patient’s story and providing what the patient most wants — a true caregiver. This dual-pronged approach, incorporating both an appreciation of tech developments and a profound commitment to the relationship between doctor and patient, makes Abraham a leading voice in the discussion about what quality care means now and in the future.
Derek Feeley, President and CEO, Institute for Healthcare Improvement (IHI), previously served as IHI’s Executive Vice President from 2013 to 2015, during which time he had executive-level responsibility for driving IHI’s strategy in five focus areas: Improvement Capability; Person- and Family-Centered Care; Patient Safety; Quality, Cost, and Value; and the Triple Aim. Prior to joining IHI in 2013, Mr. Feeley served as Director General for Health and Social Care in the Scottish Government and Chief Executive of the National Health Service (NHS) in Scotland. In that role, he was the principal advisor to the Scottish Government on health and health care policy and Presenters: Feeley, D., President and Chief Executive Officer, Institute for Healthcare Improvement Created Date : 9/22/2016
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28th Annual National Forum on Quality Improvement in Health Care Wednesday, December 7: Special Interest Breakfasts 7:00 AM - 7:45 AM SIB1 TBD SIB2 TBD SIB3 TBD SIB4 TBD SIB5 TBD SIB6 TBD SIB7 TBD SIB8 TBD SIB9 TBD SIB10 TBD SIB11 TBD SIB12 TBD SIB13 TBD SIB14 TBD SIB15 TBD
Wednesday, December 7: Workshop D
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28th Annual National Forum on Quality Improvement in Health Care 9:30 AM - 10:45 AM D1 Population Management and Team-Based Care Through the Lens of Health Equity
Learning Format: Rapid-Fire Sessions Track: Equity Your organization has been collecting Race, Ethnicity And Language (REAL) data—what’s next? This session will describe strategies to integrate REAL data into the workflow of team-based population care management to address health care equity. We will provide the “nuts and bolts” of implementing a successful program to engage leaders and discuss the unique benefits of cultural tailoring to unlock the keys to patient-centered care for racial and ethnic populations. After this presentation, participants will be able to:
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Identify the key components of an effective population management program that includes teambased care to address health equity
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Implement steps to integrate REAL data into quality improvement programs
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Develop culturally tailored interventions to promote coordinated, patient-centered care for racial and ethnic populations
Presenters: Bartolome, R., RN, PHN, MHA, National Quality Leader, Kaiser Permanente; Arakelian, A., PharmD, Director, Pharmacy Quality & Medication Safety, Kaiser Permanente; Joshua, A., MPH, Clinical Consultant, Kaiser Permanente; Gould, B., RN, MNA, Sr Director, Quality, Hospital Oversight, Equitable Care, Kaiser Permanente; Wilkes-Grundy, M., Physician, Kaiser Permanente - West Los Angeles Medical Center D2 Tools to Reduce Unconscious Bias in Decision-Making
Learning Format: Buzz Session Track: Equity Health disparities create over $309 billion in excess costs annually. Research shows that minority patients receive lower-quality health care, are routinely undertreated for pain, and receive significantly less preventive care. The Institute of Medicine has identified unconscious bias among medical professionals as a notable cause of disparities in health care. This interactive session will review the causes of unconscious bias, its implications for medical decision-making, and evidence-based strategies to reduce it. After this presentation, participants will be able to:
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Demonstrate the mechanics of unconscious bias, its psychological and neurological underpinnings, and its effects on medical decision-making and health disparities
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Recognize instances of unconscious bias in professional medical settings and apply specific evidencebased strategies to prevent its interference in medical decision-making
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Incorporate evidence-based strategies to prevent unconscious bias in their daily practice and medical encounters
Presenters: Gupta, A., Co-Founder & CEO, Be More America; Gupta, V., Co-Founder, Be More America
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28th Annual National Forum on Quality Improvement in Health Care D3 Accelerating High Reliability by Aligning Quality
Learning Format: Lecture Track: Improvement Capability To accelerate the high reliability journey, a 12-hospital health system established a highly aligned, enterprisewide approach to coordinating and integrating all quality, patient safety, and infection control (QPSIC) initiatives. This required organizational consensus on multiple levels, including goals for seven high-level QPSIC functions, governance, organizational structure, communication plans, job descriptions, and scope. This session will detail the result: a dynamic culture that achieved new levels of performance in safety, quality, and efficiency. After this presentation, participants will be able to:
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Articulate the allegiance and behavioral commitment needed to achieve effective leadership across an enterprise-wide effort in high reliability
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Examine the challenges in moving from the traditional model that prioritizes patient safety to a highreliability culture that creates safety
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Understand the tactical steps to aligning or centralizing quality and patient safety functions across a complex system
Presenters: Inurria, J., FACHE, FABC, CPHQ, Vice President, Quality and Safety, Memorial Hermann; Shippy, A., MD, FHM, System Chief Quality Officer, Memorial Hermann D4 Centralizing Multi-Hospital Mortality Reviews
Learning Format: Lecture Track: Improvement Capability Delivering the safest care with the lowest preventable harm and mortality rates is a quality priority for Northwell Health, which established a centralized, standardized mortality review (MR) process to reduce preventable deaths across 13 diverse hospitals. The process evolved from primary reviews by RNs using the IHI 2x2 Matrix to more extensive reviews, database development, and local secondary physician reviews. In this session, we will discuss the results from over 12,000 MRs as well as value-based initiatives. After this presentation, participants will be able to:
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Describe the centralized MR process used at Northwell Health
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Discuss key findings of the primary and secondary reviews
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Explain how a centralized MR process can enhance patient safety, improve quality of care, and support value-based purchasing initiatives across a multi-hospital organization
Presenters: Jarrett, M., MD, MBA, MS, Senior Vice President, Associate Chief Medical Officer and Chief Quality Officer, Northwell Health; Nelson, K., RN, MBA, CPHQ, Vice President, Institute for Clinical Excellence and Quality, Northwell Health; Schultz, S., RN, MBA, AVP, Northwell Health; Moodhe, C., Chairman of Medical Board, No Organization
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28th Annual National Forum on Quality Improvement in Health Care D5 Designing and Managing Improvement for Results
Learning Format: Lecture Track: Improvement Capability Applying improvement methods readily leads to great plans for improvement initiatives, but these plans cannot be implemented until colleagues reach a common understanding. This session will provide practical tools for putting an improvement plan into action. Participants will learn how these tools align with five core design components: setting an aim, defining a change theory and strategy for execution, identifying a measurement feedback system, and a plan to share learning. After this presentation, participants will be able to:
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Design a proper plan for an improvement initiative
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Use practical tools for managing the execution of the plan and the work
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Create a method for sharing key learnings from their work
Presenters: Williams, D., Ph.D., Executive Director, Institute for Healthcare Improvement; Parry, G., PhD, Senior Scientist, Institute for Healthcare Improvement D6 Practical Strategies for Managing Successful Improvement Projects
Learning Format: Buzz Session Track: Improvement Capability Like any project, improvement projects need project management, but effectively managing improvement projects requires distinct skills that integrate improvement methods and tools with those typical in project management to drive those projects to results. In this session, we will present key principles to strengthen the management of your improvement efforts as well as tactical tools and examples to make these principles come to life. These tools will help you lead more successful, sustainable projects in the long run. After this presentation, participants will be able to:
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Describe key principles of more effectively managing improvement projects
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Identify a few tools, including aspects of coaching, that will help them better manage their improvement projects
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Apply these principles and tools to strengthen their own improvement work
Presenters: Gunther-Murphy, C., Executive Director, Institute for Healthcare Improvement; Baldoza, K., MSW, Executive Director, Institute for Healthcare Improvement; Spranger, J., Quality Improvement Specialist, University Hospital; Heatley, G., MD, MMM, Vice Chair, Ophthalmology, UW Health D7 Question Time
Learning Format: Flipped Classroom Track: Improvement Capability Tap into decades of quality improvement experience by bringing your QI program to the session to get advice or comment from Don, Maureen, Paul, and John, learn from others in the room, and absorb the improvement molecules vibrating around the space. After commencing with a brief key career learning point from each panel member, the majority of the session will be question time. We will enable submission of queries online in advance and also take questions during the session. After this presentation, participants will be able to:
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Gain learning to advance their own quality improvement program or project
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Make sustaining contacts
Presenters: Oldham, S., MB, ChB, MBA, Adjunct Professor Institute of Global Health Innovation, Imperial College London; Berwick, D., MD, MPP, President Emeritus and Senior Fellow, IHI, Institute for Healthcare Improvement; Bisognano, M., President Emerita and Senior Fellow, Institute for Healthcare Improvement; Miles, P., MD, Senior Vice President Director of Quality & MOC, American Board of Pediatrics D8 Six Strategies for Accelerating Learning and Spread
Learning Format: Buzz Session Track: Improvement Capability Why is it that so many pilots in the field rarely have an impact when adopted more broadly? Presenters from Kaiser Permanente will share an organizational approach to learning and spread at scale that integrates innovation with improvement. This session will allow participants to apply the thinking and strategies to key strategic problems and determine how those strategies can be used to solve care delivery challenges at scale. After this presentation, participants will be able to:
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Understand a framework that aligns the science of learning and improvement with design for largerscale adoption
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Describe techniques for learning about practice variation using data that determine whether they have an effective practice
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Discuss how leaders can make effective decisions about adopting and investing in programs
Presenters: Schilling, L., RN, MPH, National Vice President, Healthcare Performance Improvement, Kaiser Permanente; Jones, J., PhD, Vice President, Information Strategy for Care Transformation, Kaiser Permanente D9 Understanding Variation in Data
Learning Format: Buzz Session Track: Improvement Capability Shewhart's theory distinguishes between common and special causes of variation in data. This session will review the implications of this theory and extend the application of Shewhart’s control chart method to publicly available data sets from health care organizations. Anytime that data is presented, we recommend asking two questions: (1) Is the process currently stable (are there special causes we can learn from)? and (2) Based on this knowledge, what type of action makes sense? After this presentation, participants will be able to:
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Describe Shewhart’s theory of variation
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Identify some of their data reports for which Shewhart charts should be used
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Implement Shewhart’s method of control charts to promote learning from their data reports
Presenters: Provost, L., MS, Statistician, Associates in Process Improvement; Perla, R., President, Health Leads
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28th Annual National Forum on Quality Improvement in Health Care D10 Breaking the Rules for Better Care
Learning Format: To Be Determined Track: Joy in Work As health care leaders, we may create or promote rules, policies, and habits with the best of intentions but do little to improve the care experience for patients, families, or staff. Recently, members of IHI’s Leadership Alliance asked patients and staff: "If you could break or change one rule in service of better care for patients or staff, what would it be and why?” In this session, we will share the hundreds of illuminating and galvanizing responses. After this presentation, participants will be able to:
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Develop effective strategies for determining which rules need to be broken within their own organization
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Discover common categories of rules
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Identify mechanisms for prioritizing and taking action on rules
Presenters: Loehrer, S., MD, MPH, Head of North America Region, Institute for Healthcare Improvement; Candiello, C., Vice President, Quality and Patient Safety, GBMC HealthCare System; Woodman, C., Chief, Strategy & Quality, Women's college hospital D11 Building Joy in Work
Learning Format: Lecture Track: Leadership This session will focus on building greater joy in work and engaging all staff in the mission and vision of the organization. Focusing on cultural alignment and care processes to effectively and efficiently drive execution and strategy requires an intentional design. This presentation will address specific initiatives at two organizations to empower and engage leaders, physicians, clinicians, and staff to foster collaboration and build joy in work within their daily practices. After this presentation, participants will be able to:
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Identify a framework for cultural alignment within their organization that supports their mission and vision
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Build the capacity to involve and engage all members of the care team to contribute their talents to improvements within the organization
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Support and develop local leaders to foster joy in work within their teams
Presenters: Averbeck, B., MD, Senior Medical Director, Primary Care, HealthPartners; Knox, P., MS, BS, Executive Vice President, Chief Learning and Innovation Office, Bellin Health; Rocheleau, J., MBA, Vice President System Support Services, Bellin Health; Hieb, L., BSN, RN, MBA, NE-BC, CNO, Bellin Health
Created Date : 9/22/2016
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28th Annual National Forum on Quality Improvement in Health Care D12 10 Lessons from the Field for Leaders
Learning Format: Lecture Track: Leadership Tackling emerging financial, demographic, and epidemiological challenges requires fresh leadership and governance ideas from different countries and industries. The presenters will share their experiences and observations from leading and governing organizations and offer practical applications to the most pressing challenges. After this presentation, participants will be able to:
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Describe the power of sound leadership and governance in taking on emerging challenges in health care
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Apply practical lessons from management and sports to performing in the face of challenges
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Identify their own new and essential roles and actions as leaders to reach the Triple Aim
Presenters: Delgado, P., MSc, Executive Director, Institute for Healthcare Improvement; Henriks, G., Chief Executive of Learning and Innovation, Qulturum; McCaughey, H., Chief Executive, South Eastern Heath and Social Care Trust D13 High-Impact Leadership
Learning Format: Lecture Improvement and innovation in health care require leadership at all levels of the organization. The authors of the popular IHI High-Impact Leadership White Paper will provide an update on their thinking and lead an interactive session on the critical need for leadership not only at the top but at all levels of an organization in order to deliver results, restore joy in work, and shape culture. After this presentation, participants will be able to:
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Develop new mental models for the jobs of managers, clinicians, and team leaders
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Create individual action plans for increasing leadership effectiveness and developing the capabilities of teams
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Acquire new leadership skills and understanding of behaviors to shape desired team cultures
Presenters: Pugh, M., MPH, President, MdP Associates, LLC; Swensen, S., MD, MMM, FACR, Medical Director, Leadership & Organization Development, Mayo Clinic D14 Improving Culture: Two Decades at the Forefront
Learning Format: To Be Determined Track: Leadership The AHRQ and SAQ survey databases indicate that culture is not improving in US health care because we are not measuring the right things. We will share insights from over two decades of working with frontline teams and leaders on organizational culture, staff engagement, burnout, and resilience. We will also present integrated, mature, and actionable models—applicable across the entire health care industry—of cultural data and a robust framework against which to analyze this data to make it meaningful. After this presentation, participants will be able to:
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Develop a precise understanding of culture and its central role in achieving high reliability
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Understand how to effectively measure culture and its components across the care continuum
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Utilize practical tools that support and reinforce culture
Presenters: Frankel, A., Partner, Safe & Reliable Healthcare; Leonard, M., Partner, Safe & Reliable Healthcare; Sexton, B., Director of Patient Safety Center, Safe & Reliable Healthcare; Jamal, M., Senior Change Agent, UCSD D15 Quality Improvement as the Route to Enhancing Joy in Work
Learning Format: Rapid-Fire Sessions Track: Leadership This session will share ideas on how to support, empower, and nurture staff through embedding a culture of continuous improvement that also promotes their joy in the work. The session will present theories and case studies in how to engage and involve all staff in improving their daily work, how to pay attention to their needs, and how to develop compassionate leaders. After this presentation, participants will be able to:
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Identify the key factors related to joy in work
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Develop a framework and ideas for using quality improvement to promote joy in work
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Identify the key principles in designing quality improvement to engage and inspire staff
Presenters: Shah, A., Associate Medical Director (QI) & Consultant forensic psych, East London NHS Foundation Trust (ELFT); Evans, N., CEO, East London NHS Foundation Trust (ELFT); Cleary, K., Chief Medical Officer, East London NHS Foundation Trust (ELFT); Fitzgerald, M., Director of Governance and Corporate Planning, East London NHS Foundation Trust (ELFT) D16 Beyond HROs: Managing Patient Safety and Risk Through a Healthcare Collaborative Reliability Organization Model
Learning Format: Lecture Performance improvement models proven successful in other high-consequence industries have often brought disappointing results when emulated in health care. It may be straightforward to use a checklist in an airline cockpit or pull a “stop-the-line” cord on an assembly line, but such actions may look and feel very different in health care settings. This session will deepen our understanding of the similarities and differences between dynamic and complex industries and of the possibilities of a Healthcare Collaborative Reliability Organization (HCRO) model. After this presentation, participants will be able to:
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Describe the elements of an HCRO
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Define the similarities between health care and other high-consequence industries
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Define the differences between health care and other high-consequence industries
Presenters: Ramthun, L., RN, MSN, CPHRM, FASHRM, Vice President Risk Management, St Joseph Health System; Griffith, S., Co-Founder and Principal Collaborator, Hospital Quality Institute
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28th Annual National Forum on Quality Improvement in Health Care D17 Engaging Harmed Patients for Healing and Safety
Learning Format: Rapid-Fire Sessions Track: Patient Safety Although communicating and engaging with patients who have been harmed by medical errors and with their families can aid their healing and educate organizations about improving patient safety, complex issues arise for hospitals and providers in the process. We will provide insights from recent research and experience about the experiences of harmed patients and families; the essentials of communication and resolution programs; barriers to engaging patients in post-event learning; and practical methods to overcome these barriers. After this presentation, participants will be able to:
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Describe the impact on patients and families after patients are harmed through medical care
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Discuss the components and implementation strategies of communication and resolution programs and explore communication barriers and solutions for engaging patients and families in post-harm learning
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Examine practice and policy recommendations to balance stakeholder needs to achieve optimal outcomes for all
Presenters: Thomas, E., MD MPH, Professor of Medicine, University Texas Medical School Medicine; Ottosen, M., PhD, MSN, RN, Assistant Professor, The University of Texas Health Science Center at Houston; Bell, S., MD, Beth Israel Deaconess Medical Center; Etchegaray, J., Sr. Behavioral and Social Scientist, RAND; Gallagher, T., MD, Associate Professor of Medicine, University Of Washington D18 Improving Safety for the Sickest of the Sick
Learning Format: Lecture Track: Patient Safety Across a large geographical region, not all specialty medical services are readily available. Moreover, transferring patients with life-threatening conditions between medical centers to ensure their access to subspecialty services can have a significant impact on their outcomes. This session will detail a journey from policy development to program implementation and evaluation that involves multiple providers and coordination across 130 hospitals to ensure optimal processes and accountability for improved access to care for this vulnerable patient population. After this presentation, participants will be able to:
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Describe processes to identify gaps in access for vulnerable patients in a large health system
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Outline direct linkages from policy development to program implementation across the 130 hospitals discussed in the session
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Describe a performance management process for program monitoring and policy evaluation
Presenters: Lawless, B., Doctor, Critical Care Services Ontario; Kostrzewa, L., RN MHSc, Director, Critical Care Services Ontario
Created Date : 9/22/2016
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28th Annual National Forum on Quality Improvement in Health Care D19 Catalyzing Interprofessional Collaboration
Learning Format: Case Study Track: Person- and Family-Centered Care Collaboration among physicians, nurses, pharmacists, and other clinical and administrative professionals will become increasingly important in health care in the future. Highlighting the University of Pennsylvania Health System’s efforts to create a culture of interprofessional collaboration (IPC), this presentation will explore practices identified through a Robert Wood Johnson Foundation study that promoted IPC, describe what makes it possible for such cultures to thrive, and look at the impact on high-quality, patient-centered care. After this presentation, participants will be able to:
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Identify promising practices that can be used to create a culture of IPC in their own organization
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Develop strategies for effectively spreading and sustaining IPC practices over time
Presenters: Tomasik, J., SM, FACHE, Vice President, CFAR, Inc.; Hassmiller, S., PhD RN, Senior Advisor for Nursing, robert wood johnson foundation; Cunningham, R., PhD, RN, NEA-BC, FAAN, System Chief Nurse Executive, University of Pennsylvania Health System; Brennan, P., MD, Chief Medical Office and Senior Vice President, University Of Pennsylvania Hospital D20 Improving End-of-Life Care: A Community Approach
Learning Format: Lecture Track: Health Plans & Insurers Advancing Improv, Person- and Family-Centered Care This session will showcase innovative community initiatives developed, implemented, and supported by Excellus BCBS for the past 16 years through which member and provider interventions have addressed the difficult yet critical topic of end-of-life care. We will review the greatest challenges to end-of-life care and the key findings and recommendations of the 2014 IOM report Dying in America, focusing on advance care planning and the National Physician Orders for Life Sustaining Treatment (POLST) Paradigm program. After this presentation, participants will be able to:
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Define the key issues in, obstacles to, and requirements for improving end-of-life care
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Illustrate how one community initiative has improved quality and patient safety, ensured accessibility, and achieved the Triple Aim
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Outline a multidimensional approach that health plans and communities can take to support the Dying in America recommendations
Presenters: Bomba, P., MD, FACP, Vice President & Medical Director, Geriatrics, Excellus BlueCross BlueShield
Created Date : 9/22/2016
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28th Annual National Forum on Quality Improvement in Health Care D21 Innovating Upstream: Population Health and Maternity Medical Homes
Learning Format: Case Study Track: Person- and Family-Centered Care Providers and health plans are advancing patient-centered care during a key window of opportunity to promote Triple Aim outcomes—the perinatal period. Community Care of North Carolina’s statewide Pregnancy Medical Home initiative focuses on preterm birth prevention through provider engagement and care management. The model advanced by the Women’s Health Center of Southern Oregon, in partnership with PrimaryHealth of Josephine County, promotes integrated care with innovative methods and active participation from local payers. After this presentation, participants will be able to:
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Apply the principles of a medical home and of population health management to perinatal care
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Identify key strategies to operationalize the maternity medical home model
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Develop approaches to introducing the principles and components of the maternity medical home locally
Presenters: Berrien, K., Director of Maternal Health Programs, Community Care of North Carolina; Johnstun, J., Director of Health Strategy, Primary Health of Josephine County, LLC; Redfern, L., CMPE, Executive Director, Women's Health Center of Southern Oregon; Rakover, J., Research Associate, Institute for Healthcare Improvement D22 You, Me, and Computer Makes Three: Best Patient Experience
Learning Format: Rapid-Fire Sessions Track: Person- and Family-Centered Care The advent of electronic health records (EHR) with wired examination rooms poses a conundrum for clinicians and patients, who now interact with a “third presence” in the room. Maintaining patientcenteredness in the computer-integrated exam room is, at best, a challenge and, at worst, a recipe for disaster. Emerging from this technological intrusion are proven effective practices that light the way to optimally incorporating computers for ideal patient care and experience. After this presentation, participants will be able to:
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Identify three ways to incorporate the computer in the exam room
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Develop a plan to integrate computers into the exam room for optimal patient experience
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Identify ways in which patient experience improves with proper computer integration into the exam room
Presenters: Lewis, B., Managing Editor, DocCom; Frankel, R., Professor of Medicine, IU School of Medicine; Chisolm, M., MD, Associate Professor of Psychiatry and Behavioral Sciences, Johns Hopkins University School of Medicine
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28th Annual National Forum on Quality Improvement in Health Care D23 Building Systems for Value, Not Leverage
Learning Format: Case Study Track: Quality Cost and Value Wisconsin's AboutHealth intimately connected eight high-performing systems ($11 billion in revenue) and focused them not on market share expansion but on getting to higher quality and lower cost more quickly than they could by themselves. We will describe why and how we built this statewide model, our mistakes and struggles, and our hopes and accomplishments. Participants will join us in a discussion about other options and models for both best value and healthier populations. After this presentation, participants will be able to:
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Identify radical statewide infrastructures to provide quality and efficient health care in this fastchanging landscape
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Compare their organization's strategies to AboutHealth’s strategy to accomplish the Triple Aim
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Learn from their mistakes, successes, and struggles in building cross-regional partnerships
Presenters: Thompson, J., MD, Executive Advisor, Chief Executive Officer Emeritus, Gundersen Health System; Oneill, M., Executive Director, Gundersen Health System; Kerwin, G., FACHE, President and Chief Executive Officer, Bellin Health D24 Identifying True Cost and Creating Value for Patients
Learning Format: Lecture Track: Quality Cost and Value How well do you know your bottom line? The True Cost Methodology (TCM) identifies the actual cost to deliver care (as opposed to charges or reimbursements) for any medical or surgical condition and across the spectrum of care delivery. Learn how TCM determines accurate care pathways, the resources used in every segment of care, and cost drivers and how it tightly couples clinical and financial performance to minimize risk in using new payment models such as bundling. After this presentation, participants will be able to:
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Prepare for bundling programs
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Define how shadowing accurately and efficiently identifies the clinical pathways and process maps used to determine and drive down the cost of care delivery
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Describe how TCM enables an organization to deliver value by driving down costs while protecting and/or improving patient and family experiences and clinical outcomes
Presenters: Digioia, A., MD, Medical Director, University of Pittsburgh Medical Center (UPMC); Giarrusso, M., RN, BSN, MS, MBA, Director of Patient and Family Centered Care, University Of Pittsburgh
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28th Annual National Forum on Quality Improvement in Health Care D25 Medication Trauma Crisis: Primary Care Innovations
Learning Format: Rapid-Fire Sessions Track: Quality Cost and Value Fragmented medication management creates patient confusion and anxiety, resulting in medication trauma that, if unaddressed, can lead to higher emergency department and hospital utilization. This crisis can be alleviated by eliciting the patient’s voice and expanding pharmacy support to health care teams. The statewide pharmacist collaborative established in primary care clinics by CareOregon’s pharmacy transformation team and organized around the highest-risk patients coordinates community and hospital pharmacists and advances medication education and workflows. These innovations are establishing effective, integrated medication support. After this presentation, participants will be able to:
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Identify the impact of medication trauma on high-risk or disadvantaged patients
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Illustrate ways in which primary care can integrate clinical pharmacy services to address medication trauma
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Recognize innovative clinical pharmacist roles in patient care
Presenters: Miller, L., MPH, CPH, CPHQ, Pharmacy Innovation Specialist, CareOregon; Suchocki, A., MD, MPH, Medical Director, Clackamas County; Kuffour, N., Ambulatory Care Clinical Coordinator, CareOregon; Beasley, D., PharmD, Ambulatory Care Clinical Coordinator, CareOregon; Slater, J., Director of Pharmacy, CareOregon D26 The Value Proposition of Convenient Care: How Retail-Based Health Care Clinics Build a Culture of Health
Learning Format: To Be Determined The 2,100+ retail clinics across the country, located in high-traffic retail outlets, are staffed by nursepractitioners and physician's assistants who provide basic primary care services. This presentation will focus on the value proposition of retail clinics in providing access to high-quality, affordable care and discuss how the health care industry, both locally and globally, can increase its value proposition by utilizing retail settings to leverage emerging health care technologies and partnerships to build a culture of health. After this presentation, participants will be able to:
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Identify how retail clinics demonstrate their value proposition in achieving the goals of improving patient care and population health and reducing costs
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Discuss the business plan for retail clinics to offer accessible, affordable, and high-quality care that is comparable to or better than the care received in more traditional medical settings
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Describe the global opportunities within retail health care, including advancing technologies and opportunities for collaboration within the industry
Presenters: Davis, S., Massachusetts, Chief Nursing Officer, Partners in Health; Hansen Turton, T., Executive Director, No Organization; Patterson, A., Chief Nurse Practitioner Officer, CVS Caremark; Malone, B., CEO, National League for Nursing
Created Date : 9/22/2016
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28th Annual National Forum on Quality Improvement in Health Care D27 What Have We Learned from the Medicare Pioneer ACO Model?
Learning Format: Rapid-Fire Sessions Track: Health Plans & Insurers Advancing Improv, Quality Cost and Value Now in its last performance year, the Pioneer ACO Model is a payment reform initiative from the Center for Medicare and Medicaid Innovation enabling organizations to use accountable care concepts to align provider incentives with improvements in quality and health outcomes for patients across the ACO, while achieving savings for Medicare and patients. This session will provide an overview of the program and its cost and quality results, including patient-reported findings, and will showcase the experience of one ACO. After this presentation, participants will be able to:
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Describe the key financial and quality measurements behind the Pioneer ACO Model
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Identify the key findings and challenges from the Pioneer ACO Model after four years of operation
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Relate an example of the key steps needed to improve outcomes and patient experience
Presenters: Leung, M., PhD, Director, Healthcare Quality and Outcomes, RTI International; Anhang Price, R., Senior Policy Researcher, RAND Corporation; Ng, T., MSW, Policy Analyst, Centers for Medicare and Medicaid Services; Uiterwyk, S., Physician, Atrius Health; Berzin, O., MPH, Research Associate, Health Services Research, RTI International D28 Global Health at Home
Learning Format: Lecture Track: Quality Cost and Value Is there anything more counterintuitive than the notion that the US could benefit from health care delivery innovation in low- and middle-income nations? Too often in the US our minds are closed to new approaches and techniques developed in other countries. But there is compelling evidence that lessons from Haiti, Peru, Rwanda, and elsewhere could help the US health care system improve health and health care and reduce costs—i.e., achieve the Triple Aim. After this presentation, participants will be able to:
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Identify how the values and techniques of global health—as practiced in Peru, Haiti, and elsewhere— could contribute to achieving the Triple Aim in the US
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Demonstrate that global health values and techniques are well suited to managing populations of patients with multiple and complex chronic conditions
Presenters: Kenney, C., Author, No Organization; Hiatt, H., MD, Professor of Medicine, Harvard Global Equity Initiative; Rosenberg, M., MD, MPP, Executive Director, The Task Force for Child Survival & Development
Created Date : 9/22/2016
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28th Annual National Forum on Quality Improvement in Health Care D29 Applying Meaningful Measurement in Health and Health Care
Learning Format: Case Study Track: Triple Aim for Populations This interactive session will help participants create multilevel dashboards that enable them to more deeply understand health and health care in their own health system and community. We will share and use both the IHI Whole System Measures 2.0 and the 100 Million Healthier Lives Metrics That Matter Wizard to examine the state of current health systems and discuss initiatives that advance health and health care in both local settings and on a larger scale. After this presentation, participants will be able to:
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Apply system-level measurements to their own health systems to better understand overall performance
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Describe an applied framework for measuring health, well-being, and equity in health systems communities
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Apply practical experience and feedback in using an improvement tool for community health, wellbeing, and equity
Presenters: Stiefel, M., MPA, MS, Sr Director, CMI Center For Population Health, IHI Fellow, Kaiser Permanente; Chase, A., BS, MS, Consultant, LLC, No Organization; Martin, L., MSPH, Executive Director, Institute for Healthcare Improvement D30 Innovative Approaches to Integrating Behavioral Health and Primary Care
Learning Format: Rapid-Fire Sessions Track: Triple Aim for Populations Care provided by an interdisciplinary team that addresses patients’ medical and behavioral needs can improve outcomes and patient experience and reduce costs. This rapid-fire session will present IHI’s framework for integrating behavioral health and primary care and case studies from two innovative organizations: Cambridge Health Alliance, which is testing and implementing unique programming for care management and telepsychiatry, and CityLife Neighborhood Clinics, whose fully integrated clinics in underserved Philadelphia neighborhoods incorporate a full range of community resources in addition to medical and behavioral health care. After this presentation, participants will be able to:
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Describe IHI’s framework for integrating behavioral health and primary care
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Understand two innovative approaches to overcoming different barriers to integrating behavioral health and primary care
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Identify new ideas to test at their own organization
Presenters: Laderman, M., MSPH, Senior Research Associate, Institute for Healthcare Improvement; Benedetto, E., Project Manager, Primary Care Mental Health Integration, Cambridge Health Alliance; Hoffman, L., Mental Health Care Partner, Cambridge Health Alliance Somerville Hospital; Bradley, W., LPC, CAADC, Senior Director, Health Integration, Ampersand Health
Created Date : 9/22/2016
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28th Annual National Forum on Quality Improvement in Health Care D31 Who’s Seen My Patient? Care Coordination Barriers
Learning Format: Buzz Session Track: Health Plans & Insurers Advancing Improv, Triple Aim for Populations Providers are increasingly being held “accountable” for outcomes for a defined set of patients. This can pose unique challenges for care coordination as long as patients can still obtain care from whichever providers they wish and may be receiving care in a variety of settings. Using experiences from the Pioneer ACO Model, we will present and discuss evidence of this problem, some measure- and provider- specific challenges, and successful strategies to address these challenges. After this presentation, participants will be able to:
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Understand the challenges associated with capturing clinical quality information among different providers and across the spectrum of care
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Identify specific strategies to overcome these challenges and ways to implement them
Presenters: Hersey, C., RTI, RTI International; Brower, E., Vice President, Population Health, Atrius Health; Binu, S., MS, MBA, CMMI Contractor, CMS Innovation Center D32 Preventing Harm through the Practice of Respect
Learning Format: Flipped Classroom Track: Patient Safety Patients experience both physical and emotional harm. Preventable emotional harms are caused by the experience of disrespect. Leveraging systems for identifying, assessing and tracking preventable physical harm, we describe a novel approach to bring the same rigor to non-physical harms so as to prevent future emotional harm. We also discuss the institutional elements that form the foundation supporting this Practice of Respect, and share strategies to build those institutional elements. After this presentation, participants will be able to:
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Identify a framework for capturing, assessing and tracking emotional harms from disrespect that utilizes existing institutional resources and processes.
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Explore the foundational elements necessary to engage in the Practice of Respect, including patientfamily engagement, proactive communication after adverse events, peer support, inter-professional respect, provider safety, and organizational structure.
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Develop a roadmap for building towards the Practice of Respect, including the foundational elements, at your institution.
Presenters: Sands, K., MD, Senior Vice President, Health Care Quality, Beth Israel Deaconess Medical Center; Folcarelli, P., RN, PhD, Director of Patient Safety, Beth Israel Deaconess Medical Center; Lee, B., MSSW, Director of Social Work, Beth Israel Deaconess Medical Center; Branchaud, A., QI Project Manager, Inpatient Quality, Beth Israel Deaconess Medical Center
Wednesday, December 7: Workshop E
Created Date : 9/22/2016
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28th Annual National Forum on Quality Improvement in Health Care 11:15 AM - 12:30 PM E1 Population Management and Team-Based Care Through the Lens of Health Equity
Learning Format: Rapid-Fire Sessions Track: Equity Your organization has been collecting Race, Ethnicity And Language (REAL) data—what’s next? This session will describe strategies to integrate REAL data into the workflow of team-based population care management to address health care equity. We will provide the “nuts and bolts” of implementing a successful program to engage leaders and discuss the unique benefits of cultural tailoring to unlock the keys to patient-centered care for racial and ethnic populations. After this presentation, participants will be able to:
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Identify the key components of an effective population management program that includes teambased care to address health equity
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Implement steps to integrate REAL data into quality improvement programs
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Develop culturally tailored interventions to promote coordinated, patient-centered care for racial and ethnic populations
Presenters: Bartolome, R., RN, PHN, MHA, National Quality Leader, Kaiser Permanente; Arakelian, A., PharmD, Director, Pharmacy Quality & Medication Safety, Kaiser Permanente; Joshua, A., MPH, Clinical Consultant, Kaiser Permanente; Gould, B., RN, MNA, Sr Director, Quality, Hospital Oversight, Equitable Care, Kaiser Permanente; Wilkes-Grundy, M., Physician, Kaiser Permanente - West Los Angeles Medical Center E2 Tools to Reduce Unconscious Bias in Decision-Making
Learning Format: Buzz Session Track: Equity Health disparities create over $309 billion in excess costs annually. Research shows that minority patients receive lower-quality health care, are routinely undertreated for pain, and receive significantly less preventive care. The Institute of Medicine has identified unconscious bias among medical professionals as a notable cause of disparities in health care. This interactive session will review the causes of unconscious bias, its implications for medical decision-making, and evidence-based strategies to reduce it. After this presentation, participants will be able to:
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Demonstrate the mechanics of unconscious bias, its psychological and neurological underpinnings, and its effects on medical decision-making and health disparities
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Recognize instances of unconscious bias in professional medical settings and apply specific evidencebased strategies to prevent its interference in medical decision-making
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Incorporate evidence-based strategies to prevent unconscious bias in their daily practice and medical encounters
Presenters: Gupta, A., Co-Founder & CEO, Be More America; Gupta, V., Co-Founder, Be More America
Created Date : 9/22/2016
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28th Annual National Forum on Quality Improvement in Health Care E3 Accelerating High Reliability by Aligning Quality
Learning Format: Lecture Track: Improvement Capability To accelerate the high reliability journey, a 12-hospital health system established a highly aligned, enterprisewide approach to coordinating and integrating all quality, patient safety, and infection control (QPSIC) initiatives. This required organizational consensus on multiple levels, including goals for seven high-level QPSIC functions, governance, organizational structure, communication plans, job descriptions, and scope. This session will detail the result: a dynamic culture that achieved new levels of performance in safety, quality, and efficiency. After this presentation, participants will be able to:
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Articulate the allegiance and behavioral commitment needed to achieve effective leadership across an enterprise-wide effort in high reliability
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Examine the challenges in moving from the traditional model that prioritizes patient safety to a highreliability culture that creates safety
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Understand the tactical steps to aligning or centralizing quality and patient safety functions across a complex system
Presenters: Inurria, J., FACHE, FABC, CPHQ, Vice President, Quality and Safety, Memorial Hermann; Shippy, A., MD, FHM, System Chief Quality Officer, Memorial Hermann E4 Centralizing Multi-Hospital Mortality Reviews
Learning Format: Lecture Track: Improvement Capability Delivering the safest care with the lowest preventable harm and mortality rates is a quality priority for Northwell Health, which established a centralized, standardized mortality review (MR) process to reduce preventable deaths across 13 diverse hospitals. The process evolved from primary reviews by RNs using the IHI 2x2 Matrix to more extensive reviews, database development, and local secondary physician reviews. In this session, we will discuss the results from over 12,000 MRs as well as value-based initiatives. After this presentation, participants will be able to:
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Describe the centralized MR process used at Northwell Health
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Discuss key findings of the primary and secondary reviews
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Explain how a centralized MR process can enhance patient safety, improve quality of care, and support value-based purchasing initiatives across a multi-hospital organization
Presenters: Jarrett, M., MD, MBA, MS, Senior Vice President, Associate Chief Medical Officer and Chief Quality Officer, Northwell Health; Nelson, K., RN, MBA, CPHQ, Vice President, Institute for Clinical Excellence and Quality, Northwell Health; Schultz, S., RN, MBA, AVP, Northwell Health; Moodhe, C., Chairman of Medical Board, No Organization
Created Date : 9/22/2016
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28th Annual National Forum on Quality Improvement in Health Care E5 Designing and Managing Improvement for Results
Learning Format: Lecture Track: Improvement Capability Applying improvement methods readily leads to great plans for improvement initiatives, but these plans cannot be implemented until colleagues reach a common understanding. This session will provide practical tools for putting an improvement plan into action. Participants will learn how these tools align with five core design components: setting an aim, defining a change theory and strategy for execution, identifying a measurement feedback system, and a plan to share learning. After this presentation, participants will be able to:
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Design a proper plan for an improvement initiative
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Use practical tools for managing the execution of the plan and the work
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Create a method for sharing key learnings from their work
Presenters: Williams, D., Ph.D., Executive Director, Institute for Healthcare Improvement; Parry, G., PhD, Senior Scientist, Institute for Healthcare Improvement E6 Practical Strategies for Managing Successful Improvement Projects
Learning Format: Buzz Session Track: Improvement Capability Like any project, improvement projects need project management, but effectively managing improvement projects requires distinct skills that integrate improvement methods and tools with those typical in project management to drive those projects to results. In this session, we will present key principles to strengthen the management of your improvement efforts as well as tactical tools and examples to make these principles come to life. These tools will help you lead more successful, sustainable projects in the long run. After this presentation, participants will be able to:
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Describe key principles of more effectively managing improvement projects
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Identify a few tools, including aspects of coaching, that will help them better manage their improvement projects
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Apply these principles and tools to strengthen their own improvement work
Presenters: Gunther-Murphy, C., Executive Director, Institute for Healthcare Improvement; Baldoza, K., MSW, Executive Director, Institute for Healthcare Improvement; Spranger, J., Quality Improvement Specialist, University Hospital; Heatley, G., MD, MMM, Vice Chair, Ophthalmology, UW Health E7 Question Time
Learning Format: Flipped Classroom Track: Improvement Capability Tap into decades of quality improvement experience by bringing your QI program to the session to get advice or comment from Don, Maureen, Paul, and John, learn from others in the room, and absorb the improvement molecules vibrating around the space. After commencing with a brief key career learning point from each panel member, the majority of the session will be question time. We will enable submission of queries online in advance and also take questions during the session. After this presentation, participants will be able to:
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Gain learning to advance their own quality improvement program or project
Created Date : 9/22/2016
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28th Annual National Forum on Quality Improvement in Health Care •
Make sustaining contacts
Presenters: Oldham, S., MB, ChB, MBA, Adjunct Professor Institute of Global Health Innovation, Imperial College London; Berwick, D., MD, MPP, President Emeritus and Senior Fellow, IHI, Institute for Healthcare Improvement; Bisognano, M., President Emerita and Senior Fellow, Institute for Healthcare Improvement; Miles, P., MD, Senior Vice President Director of Quality & MOC, American Board of Pediatrics E8 Six Strategies for Accelerating Learning and Spread
Learning Format: Buzz Session Track: Improvement Capability Why is it that so many pilots in the field rarely have an impact when adopted more broadly? Presenters from Kaiser Permanente will share an organizational approach to learning and spread at scale that integrates innovation with improvement. This session will allow participants to apply the thinking and strategies to key strategic problems and determine how those strategies can be used to solve care delivery challenges at scale. After this presentation, participants will be able to:
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Understand a framework that aligns the science of learning and improvement with design for largerscale adoption
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Describe techniques for learning about practice variation using data that determine whether they have an effective practice
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Discuss how leaders can make effective decisions about adopting and investing in programs
Presenters: Schilling, L., RN, MPH, National Vice President, Healthcare Performance Improvement, Kaiser Permanente; Jones, J., PhD, Vice President, Information Strategy for Care Transformation, Kaiser Permanente E9 Understanding Variation in Data
Learning Format: Buzz Session Track: Improvement Capability Shewhart's theory distinguishes between common and special causes of variation in data. This session will review the implications of this theory and extend the application of Shewhart’s control chart method to publicly available data sets from health care organizations. Anytime that data is presented, we recommend asking two questions: (1) Is the process currently stable (are there special causes we can learn from)? and (2) Based on this knowledge, what type of action makes sense? After this presentation, participants will be able to:
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Describe Shewhart’s theory of variation
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Identify some of their data reports for which Shewhart charts should be used
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Implement Shewhart’s method of control charts to promote learning from their data reports
Presenters: Provost, L., MS, Statistician, Associates in Process Improvement; Perla, R., President, Health Leads
Created Date : 9/22/2016
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28th Annual National Forum on Quality Improvement in Health Care E10 Breaking the Rules for Better Care
Learning Format: To Be Determined Track: Joy in Work As health care leaders, we may create or promote rules, policies, and habits with the best of intentions but do little to improve the care experience for patients, families, or staff. Recently, members of IHI’s Leadership Alliance asked patients and staff: "If you could break or change one rule in service of better care for patients or staff, what would it be and why?” In this session, we will share the hundreds of illuminating and galvanizing responses. After this presentation, participants will be able to:
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Develop effective strategies for determining which rules need to be broken within their own organization
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Discover common categories of rules
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Identify mechanisms for prioritizing and taking action on rules
Presenters: Loehrer, S., MD, MPH, Head of North America Region, Institute for Healthcare Improvement; Candiello, C., Vice President, Quality and Patient Safety, GBMC HealthCare System; Woodman, C., Chief, Strategy & Quality, Women's college hospital E11 Building Joy in Work
Learning Format: Lecture Track: Leadership This session will focus on building greater joy in work and engaging all staff in the mission and vision of the organization. Focusing on cultural alignment and care processes to effectively and efficiently drive execution and strategy requires an intentional design. This presentation will address specific initiatives at two organizations to empower and engage leaders, physicians, clinicians, and staff to foster collaboration and build joy in work within their daily practices. After this presentation, participants will be able to:
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Identify a framework for cultural alignment within their organization that supports their mission and vision
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Build the capacity to involve and engage all members of the care team to contribute their talents to improvements within the organization
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Support and develop local leaders to foster joy in work within their teams
Presenters: Averbeck, B., MD, Senior Medical Director, Primary Care, HealthPartners; Knox, P., MS, BS, Executive Vice President, Chief Learning and Innovation Office, Bellin Health; Rocheleau, J., MBA, Vice President System Support Services, Bellin Health; Hieb, L., BSN, RN, MBA, NE-BC, CNO, Bellin Health
Created Date : 9/22/2016
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28th Annual National Forum on Quality Improvement in Health Care E12 10 Lessons from the Field for Leaders
Learning Format: Lecture Track: Leadership Tackling emerging financial, demographic, and epidemiological challenges requires fresh leadership and governance ideas from different countries and industries. The presenters will share their experiences and observations from leading and governing organizations and offer practical applications to the most pressing challenges. After this presentation, participants will be able to:
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Describe the power of sound leadership and governance in taking on emerging challenges in health care
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Apply practical lessons from management and sports to performing in the face of challenges
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Identify their own new and essential roles and actions as leaders to reach the Triple Aim
Presenters: Delgado, P., MSc, Executive Director, Institute for Healthcare Improvement; Henriks, G., Chief Executive of Learning and Innovation, Qulturum; McCaughey, H., Chief Executive, South Eastern Heath and Social Care Trust E13 High-Impact Leadership
Learning Format: Lecture Improvement and innovation in health care require leadership at all levels of the organization. The authors of the popular IHI High-Impact Leadership White Paper will provide an update on their thinking and lead an interactive session on the critical need for leadership not only at the top but at all levels of an organization in order to deliver results, restore joy in work, and shape culture. After this presentation, participants will be able to:
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Develop new mental models for the jobs of managers, clinicians, and team leaders
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Create individual action plans for increasing leadership effectiveness and developing the capabilities of teams
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Acquire new leadership skills and understanding of behaviors to shape desired team cultures
Presenters: Pugh, M., MPH, President, MdP Associates, LLC; Swensen, S., MD, MMM, FACR, Medical Director, Leadership & Organization Development, Mayo Clinic E14 Improving Culture: Two Decades at the Forefront
Learning Format: To Be Determined Track: Leadership The AHRQ and SAQ survey databases indicate that culture is not improving in US health care because we are not measuring the right things. We will share insights from over two decades of working with frontline teams and leaders on organizational culture, staff engagement, burnout, and resilience. We will also present integrated, mature, and actionable models—applicable across the entire health care industry—of cultural data and a robust framework against which to analyze this data to make it meaningful. After this presentation, participants will be able to:
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Develop a precise understanding of culture and its central role in achieving high reliability
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Understand how to effectively measure culture and its components across the care continuum
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Utilize practical tools that support and reinforce culture
Presenters: Frankel, A., Partner, Safe & Reliable Healthcare; Leonard, M., Partner, Safe & Reliable Healthcare; Sexton, B., Director of Patient Safety Center, Safe & Reliable Healthcare; Jamal, M., Senior Change Agent, UCSD E15 Quality Improvement as the Route to Enhancing Joy in Work
Learning Format: Rapid-Fire Sessions Track: Leadership This session will share ideas on how to support, empower, and nurture staff through embedding a culture of continuous improvement that also promotes their joy in the work. The session will present theories and case studies in how to engage and involve all staff in improving their daily work, how to pay attention to their needs, and how to develop compassionate leaders. After this presentation, participants will be able to:
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Identify the key factors related to joy in work
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Develop a framework and ideas for using quality improvement to promote joy in work
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Identify the key principles in designing quality improvement to engage and inspire staff
Presenters: Shah, A., Associate Medical Director (QI) & Consultant forensic psych, East London NHS Foundation Trust (ELFT); Evans, N., CEO, East London NHS Foundation Trust (ELFT); Cleary, K., Chief Medical Officer, East London NHS Foundation Trust (ELFT); Fitzgerald, M., Director of Governance and Corporate Planning, East London NHS Foundation Trust (ELFT) E16 Beyond HROs: Managing Patient Safety and Risk Through a Healthcare Collaborative Reliability Organization Model
Learning Format: Lecture Performance improvement models proven successful in other high-consequence industries have often brought disappointing results when emulated in health care. It may be straightforward to use a checklist in an airline cockpit or pull a “stop-the-line” cord on an assembly line, but such actions may look and feel very different in health care settings. This session will deepen our understanding of the similarities and differences between dynamic and complex industries and of the possibilities of a Healthcare Collaborative Reliability Organization (HCRO) model. After this presentation, participants will be able to:
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Describe the elements of an HCRO
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Define the similarities between health care and other high-consequence industries
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Define the differences between health care and other high-consequence industries
Presenters: Ramthun, L., RN, MSN, CPHRM, FASHRM, Vice President Risk Management, St Joseph Health System; Griffith, S., Co-Founder and Principal Collaborator, Hospital Quality Institute
Created Date : 9/22/2016
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28th Annual National Forum on Quality Improvement in Health Care E17 Engaging Harmed Patients for Healing and Safety
Learning Format: Rapid-Fire Sessions Track: Patient Safety Although communicating and engaging with patients who have been harmed by medical errors and with their families can aid their healing and educate organizations about improving patient safety, complex issues arise for hospitals and providers in the process. We will provide insights from recent research and experience about the experiences of harmed patients and families; the essentials of communication and resolution programs; barriers to engaging patients in post-event learning; and practical methods to overcome these barriers. After this presentation, participants will be able to:
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Describe the impact on patients and families after patients are harmed through medical care
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Discuss the components and implementation strategies of communication and resolution programs and explore communication barriers and solutions for engaging patients and families in post-harm learning
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Examine practice and policy recommendations to balance stakeholder needs to achieve optimal outcomes for all
Presenters: Thomas, E., MD MPH, Professor of Medicine, University Texas Medical School Medicine; Ottosen, M., PhD, MSN, RN, Assistant Professor, The University of Texas Health Science Center at Houston; Bell, S., MD, Beth Israel Deaconess Medical Center; Etchegaray, J., Sr. Behavioral and Social Scientist, RAND; Gallagher, T., MD, Associate Professor of Medicine, University Of Washington E18 Improving Safety for the Sickest of the Sick
Learning Format: Lecture Track: Patient Safety Across a large geographical region, not all specialty medical services are readily available. Moreover, transferring patients with life-threatening conditions between medical centers to ensure their access to subspecialty services can have a significant impact on their outcomes. This session will detail a journey from policy development to program implementation and evaluation that involves multiple providers and coordination across 130 hospitals to ensure optimal processes and accountability for improved access to care for this vulnerable patient population. After this presentation, participants will be able to:
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Describe processes to identify gaps in access for vulnerable patients in a large health system
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Outline direct linkages from policy development to program implementation across the 130 hospitals discussed in the session
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Describe a performance management process for program monitoring and policy evaluation
Presenters: Lawless, B., Doctor, Critical Care Services Ontario; Kostrzewa, L., RN MHSc, Director, Critical Care Services Ontario
Created Date : 9/22/2016
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28th Annual National Forum on Quality Improvement in Health Care E19 Catalyzing Interprofessional Collaboration
Learning Format: Case Study Track: Person- and Family-Centered Care Collaboration among physicians, nurses, pharmacists, and other clinical and administrative professionals will become increasingly important in health care in the future. Highlighting the University of Pennsylvania Health System’s efforts to create a culture of interprofessional collaboration (IPC), this presentation will explore practices identified through a Robert Wood Johnson Foundation study that promoted IPC, describe what makes it possible for such cultures to thrive, and look at the impact on high-quality, patient-centered care. After this presentation, participants will be able to:
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Identify promising practices that can be used to create a culture of IPC in their own organization
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Develop strategies for effectively spreading and sustaining IPC practices over time
Presenters: Tomasik, J., SM, FACHE, Vice President, CFAR, Inc.; Hassmiller, S., PhD RN, Senior Advisor for Nursing, robert wood johnson foundation; Cunningham, R., PhD, RN, NEA-BC, FAAN, System Chief Nurse Executive, University of Pennsylvania Health System; Brennan, P., MD, Chief Medical Office and Senior Vice President, University Of Pennsylvania Hospital E20 Improving End-of-Life Care: A Community Approach
Learning Format: Lecture Track: Health Plans & Insurers Advancing Improv, Person- and Family-Centered Care This session will showcase innovative community initiatives developed, implemented, and supported by Excellus BCBS for the past 16 years through which member and provider interventions have addressed the difficult yet critical topic of end-of-life care. We will review the greatest challenges to end-of-life care and the key findings and recommendations of the 2014 IOM report Dying in America, focusing on advance care planning and the National Physician Orders for Life Sustaining Treatment (POLST) Paradigm program. After this presentation, participants will be able to:
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Define the key issues in, obstacles to, and requirements for improving end-of-life care
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Illustrate how one community initiative has improved quality and patient safety, ensured accessibility, and achieved the Triple Aim
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Outline a multidimensional approach that health plans and communities can take to support the Dying in America recommendations
Presenters: Bomba, P., MD, FACP, Vice President & Medical Director, Geriatrics, Excellus BlueCross BlueShield
Created Date : 9/22/2016
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28th Annual National Forum on Quality Improvement in Health Care E21 Innovating Upstream: Population Health and Maternity Medical Homes
Learning Format: Case Study Track: Person- and Family-Centered Care Providers and health plans are advancing patient-centered care during a key window of opportunity to promote Triple Aim outcomes—the perinatal period. Community Care of North Carolina’s statewide Pregnancy Medical Home initiative focuses on preterm birth prevention through provider engagement and care management. The model advanced by the Women’s Health Center of Southern Oregon, in partnership with PrimaryHealth of Josephine County, promotes integrated care with innovative methods and active participation from local payers. After this presentation, participants will be able to:
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Apply the principles of a medical home and of population health management to perinatal care
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Identify key strategies to operationalize the maternity medical home model
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Develop approaches to introducing the principles and components of the maternity medical home locally
Presenters: Berrien, K., Director of Maternal Health Programs, Community Care of North Carolina; Johnstun, J., Director of Health Strategy, Primary Health of Josephine County, LLC; Redfern, L., CMPE, Executive Director, Women's Health Center of Southern Oregon; Rakover, J., Research Associate, Institute for Healthcare Improvement E22 You, Me, and Computer Makes Three: Best Patient Experience
Learning Format: Rapid-Fire Sessions Track: Person- and Family-Centered Care The advent of electronic health records (EHR) with wired examination rooms poses a conundrum for clinicians and patients, who now interact with a “third presence” in the room. Maintaining patientcenteredness in the computer-integrated exam room is, at best, a challenge and, at worst, a recipe for disaster. Emerging from this technological intrusion are proven effective practices that light the way to optimally incorporating computers for ideal patient care and experience. After this presentation, participants will be able to:
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Identify three ways to incorporate the computer in the exam room
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Develop a plan to integrate computers into the exam room for optimal patient experience
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Identify ways in which patient experience improves with proper computer integration into the exam room
Presenters: Lewis, B., Managing Editor, DocCom; Frankel, R., Professor of Medicine, IU School of Medicine; Chisolm, M., MD, Associate Professor of Psychiatry and Behavioral Sciences, Johns Hopkins University School of Medicine
Created Date : 9/22/2016
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28th Annual National Forum on Quality Improvement in Health Care E23 Building Systems for Value, Not Leverage
Learning Format: Case Study Track: Quality Cost and Value Wisconsin's AboutHealth intimately connected eight high-performing systems ($11 billion in revenue) and focused them not on market share expansion but on getting to higher quality and lower cost more quickly than they could by themselves. We will describe why and how we built this statewide model, our mistakes and struggles, and our hopes and accomplishments. Participants will join us in a discussion about other options and models for both best value and healthier populations. After this presentation, participants will be able to:
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Identify radical statewide infrastructures to provide quality and efficient health care in this fastchanging landscape
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Compare their organization's strategies to AboutHealth’s strategy to accomplish the Triple Aim
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Learn from their mistakes, successes, and struggles in building cross-regional partnerships
Presenters: Thompson, J., MD, Executive Advisor, Chief Executive Officer Emeritus, Gundersen Health System; Oneill, M., Executive Director, Gundersen Health System; Kerwin, G., FACHE, President and Chief Executive Officer, Bellin Health E24 Identifying True Cost and Creating Value for Patients
Learning Format: Lecture Track: Quality Cost and Value How well do you know your bottom line? The True Cost Methodology (TCM) identifies the actual cost to deliver care (as opposed to charges or reimbursements) for any medical or surgical condition and across the spectrum of care delivery. Learn how TCM determines accurate care pathways, the resources used in every segment of care, and cost drivers and how it tightly couples clinical and financial performance to minimize risk in using new payment models such as bundling. After this presentation, participants will be able to:
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Prepare for bundling programs
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Define how shadowing accurately and efficiently identifies the clinical pathways and process maps used to determine and drive down the cost of care delivery
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Describe how TCM enables an organization to deliver value by driving down costs while protecting and/or improving patient and family experiences and clinical outcomes
Presenters: Digioia, A., MD, Medical Director, University of Pittsburgh Medical Center (UPMC); Giarrusso, M., RN, BSN, MS, MBA, Director of Patient and Family Centered Care, University Of Pittsburgh
Created Date : 9/22/2016
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28th Annual National Forum on Quality Improvement in Health Care E25 Medication Trauma Crisis: Primary Care Innovations
Learning Format: Rapid-Fire Sessions Track: Quality Cost and Value Fragmented medication management creates patient confusion and anxiety, resulting in medication trauma that, if unaddressed, can lead to higher emergency department and hospital utilization. This crisis can be alleviated by eliciting the patient’s voice and expanding pharmacy support to health care teams. The statewide pharmacist collaborative established in primary care clinics by CareOregon’s pharmacy transformation team and organized around the highest-risk patients coordinates community and hospital pharmacists and advances medication education and workflows. These innovations are establishing effective, integrated medication support. After this presentation, participants will be able to:
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Identify the impact of medication trauma on high-risk or disadvantaged patients
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Illustrate ways in which primary care can integrate clinical pharmacy services to address medication trauma
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Recognize innovative clinical pharmacist roles in patient care
Presenters: Miller, L., MPH, CPH, CPHQ, Pharmacy Innovation Specialist, CareOregon; Suchocki, A., MD, MPH, Medical Director, Clackamas County; Kuffour, N., Ambulatory Care Clinical Coordinator, CareOregon; Beasley, D., PharmD, Ambulatory Care Clinical Coordinator, CareOregon; Slater, J., Director of Pharmacy, CareOregon E26 The Value Proposition of Convenient Care: How Retail-Based Health Care Clinics Build a Culture of Health
Learning Format: To Be Determined The 2,100+ retail clinics across the country, located in high-traffic retail outlets, are staffed by nursepractitioners and physician's assistants who provide basic primary care services. This presentation will focus on the value proposition of retail clinics in providing access to high-quality, affordable care and discuss how the health care industry, both locally and globally, can increase its value proposition by utilizing retail settings to leverage emerging health care technologies and partnerships to build a culture of health. After this presentation, participants will be able to:
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Identify how retail clinics demonstrate their value proposition in achieving the goals of improving patient care and population health and reducing costs
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Discuss the business plan for retail clinics to offer accessible, affordable, and high-quality care that is comparable to or better than the care received in more traditional medical settings
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Describe the global opportunities within retail health care, including advancing technologies and opportunities for collaboration within the industry
Presenters: Davis, S., Massachusetts, Chief Nursing Officer, Partners in Health; Hansen Turton, T., Executive Director, No Organization; Patterson, A., Chief Nurse Practitioner Officer, CVS Caremark; Malone, B., CEO, National League for Nursing
Created Date : 9/22/2016
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28th Annual National Forum on Quality Improvement in Health Care E27 What Have We Learned from the Medicare Pioneer ACO Model?
Learning Format: Rapid-Fire Sessions Track: Health Plans & Insurers Advancing Improv, Quality Cost and Value Now in its last performance year, the Pioneer ACO Model is a payment reform initiative from the Center for Medicare and Medicaid Innovation enabling organizations to use accountable care concepts to align provider incentives with improvements in quality and health outcomes for patients across the ACO, while achieving savings for Medicare and patients. This session will provide an overview of the program and its cost and quality results, including patient-reported findings, and will showcase the experience of one ACO. After this presentation, participants will be able to:
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Describe the key financial and quality measurements behind the Pioneer ACO Model
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Identify the key findings and challenges from the Pioneer ACO Model after four years of operation
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Relate an example of the key steps needed to improve outcomes and patient experience
Presenters: Leung, M., PhD, Director, Healthcare Quality and Outcomes, RTI International; Anhang Price, R., Senior Policy Researcher, RAND Corporation; Ng, T., MSW, Policy Analyst, Centers for Medicare and Medicaid Services; Uiterwyk, S., Physician, Atrius Health; Berzin, O., MPH, Research Associate, Health Services Research, RTI International E28 Global Health at Home
Learning Format: Lecture Track: Quality Cost and Value Is there anything more counterintuitive than the notion that the US could benefit from health care delivery innovation in low- and middle-income nations? Too often in the US our minds are closed to new approaches and techniques developed in other countries. But there is compelling evidence that lessons from Haiti, Peru, Rwanda, and elsewhere could help the US health care system improve health and health care and reduce costs—i.e., achieve the Triple Aim. After this presentation, participants will be able to:
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Identify how the values and techniques of global health—as practiced in Peru, Haiti, and elsewhere— could contribute to achieving the Triple Aim in the US
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Demonstrate that global health values and techniques are well suited to managing populations of patients with multiple and complex chronic conditions
Presenters: Kenney, C., Author, No Organization; Hiatt, H., MD, Professor of Medicine, Harvard Global Equity Initiative; Rosenberg, M., MD, MPP, Executive Director, The Task Force for Child Survival & Development
Created Date : 9/22/2016
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28th Annual National Forum on Quality Improvement in Health Care E29 Applying Meaningful Measurement in Health and Health Care
Learning Format: Case Study Track: Triple Aim for Populations This interactive session will help participants create multilevel dashboards that enable them to more deeply understand health and health care in their own health system and community. We will share and use both the IHI Whole System Measures 2.0 and the 100 Million Healthier Lives Metrics That Matter Wizard to examine the state of current health systems and discuss initiatives that advance health and health care in both local settings and on a larger scale. After this presentation, participants will be able to:
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Apply system-level measurements to their own health systems to better understand overall performance
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Describe an applied framework for measuring health, well-being, and equity in health systems communities
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Apply practical experience and feedback in using an improvement tool for community health, wellbeing, and equity
Presenters: Stiefel, M., MPA, MS, Sr Director, CMI Center For Population Health, IHI Fellow, Kaiser Permanente; Chase, A., BS, MS, Consultant, LLC, No Organization; Martin, L., MSPH, Executive Director, Institute for Healthcare Improvement E30 Innovative Approaches to Integrating Behavioral Health and Primary Care
Learning Format: Rapid-Fire Sessions Track: Triple Aim for Populations Care provided by an interdisciplinary team that addresses patients’ medical and behavioral needs can improve outcomes and patient experience and reduce costs. This rapid-fire session will present IHI’s framework for integrating behavioral health and primary care and case studies from two innovative organizations: Cambridge Health Alliance, which is testing and implementing unique programming for care management and telepsychiatry, and CityLife Neighborhood Clinics, whose fully integrated clinics in underserved Philadelphia neighborhoods incorporate a full range of community resources in addition to medical and behavioral health care. After this presentation, participants will be able to:
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Describe IHI’s framework for integrating behavioral health and primary care
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Understand two innovative approaches to overcoming different barriers to integrating behavioral health and primary care
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Identify new ideas to test at their own organization
Presenters: Laderman, M., MSPH, Senior Research Associate, Institute for Healthcare Improvement; Benedetto, E., Project Manager, Primary Care Mental Health Integration, Cambridge Health Alliance; Hoffman, L., Mental Health Care Partner, Cambridge Health Alliance Somerville Hospital; Bradley, W., LPC, CAADC, Senior Director, Health Integration, Ampersand Health
Created Date : 9/22/2016
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28th Annual National Forum on Quality Improvement in Health Care E31 Who’s Seen My Patient? Care Coordination Barriers
Learning Format: Buzz Session Track: Health Plans & Insurers Advancing Improv, Triple Aim for Populations Providers are increasingly being held “accountable” for outcomes for a defined set of patients. This can pose unique challenges for care coordination as long as patients can still obtain care from whichever providers they wish and may be receiving care in a variety of settings. Using experiences from the Pioneer ACO Model, we will present and discuss evidence of this problem, some measure- and provider- specific challenges, and successful strategies to address these challenges. After this presentation, participants will be able to:
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Understand the challenges associated with capturing clinical quality information among different providers and across the spectrum of care
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Identify specific strategies to overcome these challenges and ways to implement them
Presenters: Hersey, C., RTI, RTI International; Brower, E., Vice President, Population Health, Atrius Health; Binu, S., MS, MBA, CMMI Contractor, CMS Innovation Center EFree Workshop E Free Time E32 Preventing Harm through the Practice of Respect
Learning Format: Flipped Classroom Track: Patient Safety Patients experience both physical and emotional harm. Preventable emotional harms are caused by the experience of disrespect. Leveraging systems for identifying, assessing and tracking preventable physical harm, we describe a novel approach to bring the same rigor to non-physical harms so as to prevent future emotional harm. We also discuss the institutional elements that form the foundation supporting this Practice of Respect, and share strategies to build those institutional elements. After this presentation, participants will be able to:
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Identify a framework for capturing, assessing and tracking emotional harms from disrespect that utilizes existing institutional resources and processes.
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Explore the foundational elements necessary to engage in the Practice of Respect, including patientfamily engagement, proactive communication after adverse events, peer support, inter-professional respect, provider safety, and organizational structure.
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Develop a roadmap for building towards the Practice of Respect, including the foundational elements, at your institution.
Presenters: Sands, K., MD, Senior Vice President, Health Care Quality, Beth Israel Deaconess Medical Center; Folcarelli, P., RN, PhD, Director of Patient Safety, Beth Israel Deaconess Medical Center; Lee, B., MSSW, Director of Social Work, Beth Israel Deaconess Medical Center; Branchaud, A., QI Project Manager, Inpatient Quality, Beth Israel Deaconess Medical Center
Wednesday, December 7: General 6:30 AM - 5:00 PM shut4 Shuttles from Marriott to Orlando Airport
12:40 PM - 1:20 PM MAL3 Meet the Author Lunch: TBD Created Date : 9/22/2016
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28th Annual National Forum on Quality Improvement in Health Care Wednesday, December 7: Keynotes 8:00 AM - 9:00 AM K3 When Tragedy Strikes: Insights and Stories from Orlando Health
Learning Format: Rapid-Fire Sessions On June 12, 2016, the deadliest mass shooting in American history took place at the Pulse Nightclub in Orlando, Florida. This tragic event unfolded only a few blocks from Central Florida’s only Level One Trauma Center at Orlando Regional Medical Center, part of the Orlando Health system. Early that morning, 44 victims with gun-shot wounds were rushed to Orlando Regional Medical Center. 35 survived their injuries. This incident shines a spotlight on a new challenge facing emergency medicine. Orlando Health’s response provides important lessons on responding to mass trauma events like the one that took place at Pulse Nightclub. Several members of Orlando Health’s care team, including members of their leadership and trauma departments, will share their stories and insights about this tragic event. These stories will give their first-hand account on what they were prepared for, and what no one could have been prepared for and describe their improvement journey, from which everyone in health care can learn.
1:30 PM - 2:30 PM K4 Donald Berwick, MD
Learning Format: Lecture Donald M. Berwick, MD, MPP, FRCP, President Emeritus and Senior Fellow, Institute for Healthcare Improvement, is also former Administrator of the Centers for Medicare & Medicaid Services. A pediatrician by background, Dr. Berwick has served on the faculty of the Harvard Medical School and Harvard School of Public Health, and on the staffs of Boston's Children's Hospital Medical Center, Massachusetts General Hospital, and the Brigham and Women's Hospital. He has also served as Vice Chair of the US Preventive Services Task Force, the first "Independent Member" of the American Hospital Association Board of Trustees, and Chair of the National Advisory Council of the Agency for Healthcare Research and Quality. He served two terms on the Institute of Medicine's (IOM's) Governing Council, was a member of the IOM's Global Health Board, and served on President Clinton's Advisory Commission on Consumer Protection and Quality in the Healthcare Industry. Recognized as a leading authority on health care quality and improvement, Dr. Berwick has received numerous awards for his contributions. In 2005, he was appointed "Honorary Knight Commander of the British Empire" by the Queen of England in recognition of his work with the British National Health Service. Dr. Berwick is the author or co-author of over 160 scientific articles and five books. He also serves as Lecturer in the Department of Health Care Policy at Harvard Medical School.? ????????? Presenters: Berwick, D., MD, MPP, FRCP, KBE, President Emeritus and Senior Fellow, Institute for Healthcare Improvement
Created Date : 9/22/2016
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