Pennsylvania Continuous Service Readiness Program. Annual Update. Holiday Inn Harrisburg-Hershey Grantville, PA

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1 Pennsylvania Continuous Service Readiness Program Annual Update Holiday Inn Harrisburg-Hershey Grantville, PA Thursday and Friday March 20 21, 2014

2 Purpose: The Pennsylvania Continuous Service Readiness Program (CSRP) is a joint effort between Joint Commission Resources (JCR) and The Hospital & Healthsystem Association of Pennsylvania (HAP) to structure and implement a program by which hospitals can receive education, consultation, and feedback on an ongoing basis from JCR and The Joint Commission (TJC) staff. At the conclusion of the workshop, the participants will be able to: 1. Identify at least one change in TJC standards since July Identify two of the most challenging standards resulting in recommendations for improvement in organizations surveyed in Describe two top challenging standards for disease-specific certification reviews. 4. Describe one of the changes in the primary stroke standards for Identify two manifestations of nurse/hospital worker fatigue. 6. Identify worker fatigue issues and solutions to prevent risks for adverse events. 7. Identify worker fatigue issues and solutions that decrease the risk to worker personal safety and well being. 8. Define the characteristics of organizations that manage serious hazards extremely well. 9. Identify the characteristics of high reliability organizations that focus on a particular culture and a set of operating and management principles. 10. Identify two of the most frequent CMS findings in organizations surveyed in Identify one best practice to implement that will insure CMS compliance. 12. Describe one strategy that could be utilized to maintain ongoing standards compliance. 13. Describe one change an organization can make to implement unit and patient safety rounds. 14. Identify one best practice strategy in the implementation of unit and patient safety rounds. 15. Identify two best practice strategies in implementation of OPPE/FPPE. 16. Identify one tactic to improve medical staff engagement with culture of safety. 17. Identify two of the most frequent problems identified with the implementation of the medical staff and leadership standards.

3 AGENDA Pennsylvania Continuous Service Readiness Program Annual Update March 20 21, 2014 Holiday Inn Harrisburg-Hershey, Grantville, PA THURSDAY, MARCH 20 7:15 a.m. 8:00 a.m. Registration and Continental Breakfast 8:00 a.m. 8:30 a.m. Welcome, Introductions. and HAP Update Carol Curran, RN, MS, CJCP, CSR Consultant Brian Smith, BS, MHA, Director, Clinical Compliance and Quality, HAP 8:30 a.m. 9:30 a.m. Joint Commission Update and Future Expectations Pat Adamski, RN, MS, MBA, FACHE Director, Standards Interpretation Group 9:30 a.m. 9:45 a.m. BREAK 9:45 a.m. 11:00 a.m. Joint Commission Update and Future Expectations (continued) Pat Adamski, RN, MS, MBA, FACHE Director, Standards Interpretation Group 11:00 a.m. 12:00 p.m. Disease Specific Certification: Top Challenging Standards & Updated Primary Stroke Standards Beth Glassford, RN, MSHA, FACHE, CJCP Field Director/Consultant, JCR 12:00 p.m. 1:00 p.m. GROUP LUNCHEON 1:00 p.m. 2:15 p.m. Healthcare Worker/Nurse Fatigue and Patient Safety Ann Scott Blouin, RN, PhD, FACHE TJC Executive Vice President, Customer Relations 2:15 p.m. 2:30 p.m. BREAK 2:30 p.m. 3:45 p.m. Risk Identification: Early Vulnerability Assessment for Proactive Harm Prevention Ann Scott Blouin, RN, PhD, FACHE TJC Executive Vice President, Customer Relations 3:45 p.m. 4:15 p.m. Open time for questions and answers with the CSR Consultants Beth Glassford, RN, MSHA, FACHE, CJCP Field Director/Consultant, JCR Karen Caywood, RN, MBA, CJCP, CSR Consultant Carol Curran, RN, MS, CJCP, CSR Consultant

4 AGENDA (continued) FRIDAY, MARCH 21 7:15 a.m. 8:00 a.m. Registration and Continental Breakfast 8:00 a.m. 8:15 a.m. Welcome and Updates Carol Curran, RN, MS, CJCP, JCR Consultant 8:15 a.m. - 9:30 a.m. CMS Update Michele McDonald, RN, MPH, Executive Director, Government Regulations & Advisory Services 9:30 a.m. 9:45 a.m. BREAK 9:45 a.m. 10:30 a.m. CMS Update (continued) Michele McDonald, RN, MPH, Executive Director, Government Regulations & Advisory Services 10:30 a.m. 12:00 p.m. Unit Based Safety Rounds Diane Gordon, RN, BS, CPHQ, Reading Hospital and Medical Center Rebecca Densmore, RN, MMGT., JCAP, Penn State Hershey Medical Center Melissa Babarsky, BS, RRT, St. Vincent s Hospital 12:00 p.m. 1:00 p.m. GROUP LUNCHEON 1:00 p.m. 2:00 p.m. Medical Staff Engagement as it Relates to OPPE and FPPE Steven Chinn, DPM, JCR Consultant 2:00 p.m. - 3:00 p.m. Medical Staff Culture of Safety and Moving Towards High Reliability Steven Chinn, DPM, JCR Consultant 3:00 p.m. 4:00 p.m. Survey Sharing Rebecca Densmore, RN, MMGT., JCAP, Penn State Hershey Medical Center Melissa Babarsky, BS, RRT, and Steve Osborn, MBA, MHA, CSSBB, CPHQ, FACHE, CJCP, St. Vincent s Hospital 4:00 p.m. ADJOURN

5 Date: Thursday and Friday, March 20 21, 2014 Location: Holiday Inn Harrisburg-Hershey, 604 Station Road, Grantville Phone: (717) Who Should Attend: This meeting is limited to participants from Pennsylvania CSR hospitals. Registration Information: Registration fee is $199 per person for both days. This fee will be charged whether you elect to attend one day or both days. Registration should be received by HAP no later than Thursday, March 13. The registration fee covers instructional materials, program room fees, coffee breaks, and lunches. The monthly CSRP subscription fee paid by participating organizations to JCR partially offsets the cost of this conference. Registration begins at 7:15 a.m. on Thursday, March 20. The program will run from 8 a.m. to 4:15 p.m. on the first day. Friday s program will run from 8 a.m. to 4 p.m. Lunch will be provided both days. Cancellation Policy: Registrants are responsible for the full fee if cancellation is received after Friday, March 14. Cancellations must be in writing. No-shows will be billed. Substitutions are permissible. Accommodations*: A limited block of rooms has been reserved at the Holiday Inn Harrisburg-Hershey for the nights of March 19 and 20. In order to guarantee yourself a room at the hotel, you must make reservations by no later than midnight on Monday, February 17. After this time, reservations will be accepted on a space available, rate available basis, and you may not be guaranteed the group room rate of $99 per room, per night (single or double occupancy), plus 6% sales tax and 5% occupancy tax (subject to change). The telephone number for Holiday Inn Harrisburg-Hershey reservations is (866) or (717) *IMPORTANT!! Please identify yourself as part of the Hospital and Healthsystem Association program when making your reservations to obtain the special room rate. PAYMENT MUST BE RECEIVED BY THE DAY OF THE PROGRAM

6 Attire: The attire for the workshop is business casual. Please dress in layers as meeting room temperature may fluctuate. Continuing Education Credits: Joint Commission Resources is accredited as a provider of continuing nursing education by the American Nurses Credentialing Center's Commission on Accreditation (ANCC). ANCC continuing education credits will be provided upon satisfying the requirements for successful completion of this continuing nursing education program activity by attending education sessions and completing the online evaluation. Joint Commission Resources designates this continuing nursing education activity for contact hours. Full attendance at every session is a prerequisite for receiving full continuing education credits. If a participant needs to leave early, his or her continuing education credits will be reduced. Future 2014 CSR Educational Dates: The following dates and locations have been planned for other CSRP educational programs: Thursday and Friday, September The Nittany Lion Inn, State College, PA Questions: Please contact: Brian Smith Director, Clinical Compliance and Quality The Hospital & Healthsystem Association of Pennsylvania 4750 Lindle Road Harrisburg, PA Ph: (717) Fax: (717)

7 The Hospital & Healthsystem Association of Pennsylvania PENNSYLVANIA CONTINUOUS SERVICE READINESS PROGRAM ANNUAL UPDATE March 20 21, 2014 Holiday Inn Harrisburg-Hershey, Grantville, PA ( ) Please type or print (For additional registrants, please make copies of this form) Name Title Credentials Hospital/Health System Address City/State/Zip Phone Registrant s * FEE: Fax (*Confirmation will be sent only to registrant s ) $199 per person from a CSRP participating organization. This fee will be charged whether you elect to attend one day or both days. You must be present at all sessions to get full ANCC CEU credits. Check payable to: HAP Education and Research Services Number Attending Amount Enclosed Visa MasterCard ONLY Authorized Charge Amount Card Number Cardholder s Name Cardholder s Signature Expiration Date Phone PRE-REGISTER BY FAX: (717) If paying by mail, fax form to (717) and follow by mailing check and form to: HAP Education Services, Box 3344, Harrisburg, PA Registration deadline: March 13 Early registration is encouraged due to limited seating. Walk-in registrations will require payment onsite. Registrants are responsible for the full fee if cancellations are received after March 14. No refunds will be issued for no-shows. Substitutions are permitted. Cancellations must be in writing. For registration information, or if you require special accommodations or have specific dietary needs, please call HAP Education and Research Services at (717)

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