Creating a Checklist Culture Chris George, RN MS cgeorge@mha.org
|
|
|
- Laurel Rice
- 8 years ago
- Views:
Transcription
1 Creating a Checklist Culture Chris George, RN MS cgeorge@mha.org
2 Objectives Benefits of using checklists What makes a good checklist Creating a culture that supports checklists
3 Why do we need checklists? Focus on 4 HAIs: VAP, SSI, CRBSI, UTI $5 billion per year excess costs 1.7 million patients per year 1 out of 20 patients 98,000 deaths per year As many deaths as breast cancer and HIV/AIDS put together 6th leading cause of preventable deaths
4 Why do we need checklists? Wrong site surgeries are still the highest reported sentinel events RAND Study shows that patients received recommended therapies about 55 percent of the time McGlynn et al, NEJM 2003; 348(26):
5 Why do these things happen? Complexity of healthcare delivery Increasing technical skills Abundant research and new discoveries Lack of teamwork and communication Every system is perfectly designed to produce the results it delivers
6 Safe system design Standardize work Reduce complexity Create independent checks for key processes (checklists) Learn from mistakes
7 Examples from other industries Aviation Construction Finance Cooking
8 Checklists in health care Drowning victim Surgical case without blood on hold Keystone ICU CRBSI reduced from statewide median of 2.7 to 0 in three months and maintained for 36 months N Engl J Med 2006;355:
9 The Michigan Keystone ICU Project saved over 1,500 lives and $200 million by reducing health care associated infections. Office of Health Reform, Department of Health and Human Services
10 Purpose/Value of Checklists Provide independent checks Practitioners don t have to rely on memory WHO Safe Surgery Checklist Complications reduced from 11% to 7% In-hospital death rate reduced from 1.5% to 0.8% Haynes et al, NEJM 2009; 360:491-9
11 Components of a good checklist Precise Efficient Easy to use in a difficult situation Mix of task and communication checks Gawande, A (2009). The Checklist Manifesto. New York: Metropolitan Books.
12 Jt Comm J Qual Saf 2006;32(6):
13 % of respondents reporting above adequate teamwork L&D RN/MD ICU RN/MD OR RN/Surg CRNA/Anesth
14 Teamwork Disconnect MD: Good teamwork means the nurse does what I say RN: Good teamwork means I am asked for my input
15 Why teamwork? Activation phenomenon Avoid silent disengagement Teamwork rated higher when the team knows each other s first names Briefings reduce perceived risk of wrongsite surgery and improve perceived collaboration among OR personnel Makary et al, J Am Coll Surg 2007; 204:
16 % reporting good teamwork climate Teamwork Climate Across Michigan ICUs The strongest predictor of clinical excellence: Do caregivers feel comfortable speaking up if they perceive a problem with patient care No BSI = 5 months or more w/ zero No BSI 21% No BSI 31% No BSI 44% Health Services Research, 2006;41(4 Part II):1599.
17 Comprehensive Unit-based Safety Program (CUSP)
18
19 Pre CUSP Work Create an interdisciplinary team Nurse, physician, administrator, others Assign a team leader Measure Culture in your clinical area Use validated survey Work with hospital quality leader to have a senior executive assigned to team
20 Comprehensive Unit-based Safety Program (CUSP) An Intervention to Learn from Mistakes and Improve Safety Culture 1. Educate staff on science of safety 2. Identify defects 3. Assign executive to adopt unit 4. Learn from one defect per quarter 5. Implement teamwork tools Pronovost J, Patient Safety, 2005
21 Step 1: Science of Safety Summary Accept that we will make mistakes Focus on systems rather than blame Standardize, create independent checks, and learn from mistakes Make harm visible-- get staff thinking about safety and how to improve it
22 Step 2: Staff Identify Defects Frontline caregivers are the eyes and ears of patient safety Identify clinical or operational problems that negatively impact patient safety (have or could) QI team review suggestions, set the agenda for discussion with executive partner
23 Staff Safety Assessment - CUSP Name: Job Category: Date: Unit: Please describe how you think the next patient in your unit/clinical area will be harmed. Please describe what you think can be done to prevent or minimize this harm. Return this form to your project leader Thank you for helping improve safety in your workplace! Copyright 2007 The Johns Hopkins Quality and Safety Research Group Page 15 Version 7.2 RWJF/Adventist ICU Project
24 Step 2: Staff Identify Defects Report the identified defects to staff, executive partner QI team prioritize defects identified by the potential level of risk to the patient Select one to work on and start Step 4 Step 2 should be ongoing
25 Step 3: Senior Executive Partnership getting started Discuss safety issues identified in Step 2 w/ your Exec. partner Exec. helps remove barriers (lack of awareness, communication, financial, political) to improvement Exec. stimulates further discussions about safety, suggests solutions to safety concerns Exec. helps set goals for the unit Exec. Looks for other units with same issues QI Team reports actions/results broadly
26 or more None % of respondents reporting positive safety climate 100 Safety Climate across 1152 Clinical Areas in EWR=Executive Walk Rounds -
27 Step 4: Learning from Defects What happened? Why? What will you do to reduce probability that it will happen again? How do you know risk is reduced? Share your learning throughout organization Jt Comm J Qual Saf Feb 2006
28 Learning Invite all who touch process to attend Learn deeply from smaller number, rather than re-educate staff on a large number Learn at different levels System/hospital: one per quarter Department: one per quarter Nursing unit: one per month Share your learning throughout organization
29 Morning Briefing Step 5: Teamwork Tools Jt Comm J Qual Patient Saf. 2005;31(8):476-9 Learning from Defects Jt Comm J Qual Patient Saf. 2006;32(2):102-8 Am J Med Qual 2009;24(3): Team Check Up Tool Jt Comm J Qual Patient Saf. 2008;34: Shadowing Jt Comm J Qual Patient Saf. 2008;34:614-8 Daily Goals Pronovost, Berenholtz, Dorman. J Crit Care 2003
30 Conclusion Why checklists are needed What makes a good checklist Creating a culture that supports the use of checklists Questions??
CUSP: Designing a Comprehensive Unit-based Patient Safety Program
This work is licensed under a Creative Commons Attribution-NonCommercial-ShareAlike License. Your use of this material constitutes acceptance of that license and the conditions of use of materials on this
The Upper Peninsula Trustee Forum. Senior Vice President Quality and Patient Safety Michigan Health & Hospital Association
Safe Care. Always. The Upper Peninsula Trustee Forum March 25, 2011 Sam R. Wt Watson Senior Vice President Quality and Patient Safety Michigan Health & Hospital Association How will your hospital harm
Translating Evidence to Safer Care Patient Safety Research Introductory Course Session 7 Albert W Wu, MD, MPH Former Senior Adviser, WHO Professor of Health Policy & Management, Johns Hopkins Bloomberg
Strategies and Tools to Enhance Performance and Patient Safety
Strategies and Tools to Enhance Performance and Patient Safety Ice Breaker Mod 1 05.2 06.2 Page 2 2 Do No Harm Jess Story Do no Harm Jess' Story Mod 1 05.2 06.2 Page 3 3 Medical Error Have you been affected
CAUTI Collaborative. Objectives. Speaker. Panelists
CAUTI Collaborative Discuss the risk of unnecessary use of Foley catheters Identify the appropriate indicators for use of a Foley catheter Define how to apply these indicators within your hospital or unit
Learning from Defects
Learning from Defects Problem Statement: Healthcare organizations could increase the extent to which they learn from defects. We define learning as reducing the probability that a future patient will be
Surgical specimen identification errors: A new measure of quality in surgical care
Surgical specimen identification errors: A new measure of quality in surgical care Martin A. Makary, MD, MPH, a,d,e Jonathan Epstein, MD, b Peter J. Pronovost, MD, PhD, a,c,d,e E. Anne Millman, MS, a,d,e
One of the Institute of Medicine s 10 rules for health
MEDICATION RECONCILIATION TOOL A Practical Tool to Reduce Medication Errors During Patient Transfer from an Intensive Care Unit Peter Pronovost, MD, PhD, Deborah Baugher Hobson, BSN, Karen Earsing, RN,
Medication error is the most common
Medication Reconciliation Transfer of medication information across settings keeping it free from error. By Jane H. Barnsteiner, PhD, RN, FAAN Medication error is the most common type of error affecting
Delivering Reliability in the Healthcare System
Introduction Delivering Reliability in the Healthcare System Dev Raheja Email: Draheja@aol.com The alarming truth for patients in US hospitals is their likelihood of dying highly correlates with their
Karen Frush, BSN, MD Chief Patient Safety Officer Duke University Health System October 23, 2009
Karen Frush, BSN, MD Chief Patient Safety Officer Duke University Health System October 23, 2009 Share our story Describe a comprehensive patient safety program Discuss culture and its importance in patient
Strategies for LEADERSHIP. Hospital Executives and Their Role in Patient Safety
Strategies for LEADERSHIP Hospital Executives and Their Role in Patient Safety 1 Effective Leadership for Patient Safety Creating and Leading Significant Change Dear Colleague: In 1995, two tragic medication
Improving Safety: Developing Safety Metrics and Improving Error Reporting. Petra Khoury, Pharm D Adnan Tahir, MD
Improving Safety: Developing Safety Metrics and Improving Error Reporting Petra Khoury, Pharm D Adnan Tahir, MD Learning Objectives List Prevalent patient safety issues reported within hospitals Identify
Quality Outcomes & Patient Safety
Quality Outcomes & Patient Safety PDCA National Patient Safety Goals Event Reporting Welcome to the lesson on Quality Outcomes, Patient Safety Goals and Event Reporting. In this lesson, we will be describing:
Operating Room Teamwork among Physicians and Nurses: Teamwork in the Eye of the Beholder
Operating Room Teamwork among Physicians and Nurses: Teamwork in the Eye of the Beholder Martin A Makary, MD, MPH, J Bryan Sexton, PhD, Julie A Freischlag, MD, FACS, Christine G Holzmueller, BLA, E Anne
Crew Resource Management
Crew Resource Management DR TIMOTHY BRAKE, SENIOR MEDICAL OFFICER, UNITED CHRISTIAN HOSPITAL HONORARY SECRETARY HKSSIH Crew Resource Management 1 Crew Resource Management I am not an expert in CRM CRM
Seven Steps to Emergency Department Patient Satisfaction in the 99 th Percentile: A Physician s Point of View
Seven Steps to Emergency Department Patient Satisfaction in the 99 th Percentile: A Physician s Point of View September 17, 2013 Speakers Todd Hold, M.D., President, Georgia Emergency Services Dr. Hold
Coming to the Table: Debriefing for Patient Safety NYSPQC Educational Webinar April 24, 2013
Coming to the Table: Debriefing for Patient Safety NYSPQC Educational Webinar April 24, 2013 Christine Arnold, RNC, MS Rita Dadiz, DO Joanne Weinschreider, RN, MS Faculty Christine Arnold, RNC, MS Project
Dora Anne Mills, MD, MPH, FAAP. dmills2@une.edu 207-221-4621
Dora Anne Mills, MD, MPH, FAAP Vice President for Clinical Affairs UNE dmills2@une.edu 207-221-4621 Karen Pardue, PhD, RN Associate Dean of Westbrook College of Health Professions, UNE KPardue@une.edu
Communication skills and error in the intensive care unit Tom W. Reader a, Rhona Flin a and Brian H. Cuthbertson b
Communication skills and error in the intensive care unit Tom W. Reader a, Rhona Flin a and Brian H. Cuthbertson b Purpose of review Poor communication in critical care teams has been frequently shown
Patient Safety. Annual Continuing Education Modules. Contents
Annual Continuing Education Modules Patient Safety This self-directed learning module contains information you are expected to know to protect yourself, our patients, and our guests. Target Audience: Contents
AHRQ Patient Safety Tools and Resources
AHRQ Patient Safety Tools and Resources The Agency for Healthcare Research and Quality (AHRQ) offers practical, research-based tools and resources to help a variety of health care organizations, providers,
The 2000 release of To Err Is Human revealed
Patient Safety Senior Executive Adopt-a-Work Unit: A Model for Safety Improvement The 2000 release of To Err Is Human revealed the significant scope and impact of medical errors on the U.S. population.
Retrospective review of the Modified Early Warning Score in critically ill surgical inpatients at a Canadian Hospital
Retrospective review of the Modified Early Warning Score in critically ill surgical inpatients at a Canadian Hospital Alisha Mills PGY 4 General Surgery Northern Ontario School of Medicine S Disclosures
EFFECTIVE COMMUNICATION is critical
J Nurs Care Qual Vol. 24, No. 3, pp. 184 188 Copyright c 2009 Wolters Kluwer Health Lippincott Williams & Wilkins The Joint Commission Update In this column an expert from The Joint Commission provides
Iowa Healthcare Collaborative (IHC) Iowa Report. CY2012 Healthcare-associated Infection (HAI) Data Collection and Reporting Guide
Iowa Healthcare Collaborative () Iowa Report Healthcare-associated Infection (HAI) Data Collection and Reporting Guide Revision Date: January 17, 2013 This document is intended to be a HAI data collection
What Is Patient Safety?
Patient Safety Research Introductory Course Session 1 What Is Patient Safety? David W. Bates, MD, MSc External Program Lead for Research, WHO Professor of Medicine, Harvard Medical School Professor of
Improving the Value of Patient Safety Reporting Systems
Improving the Value of Patient Safety Reporting Systems Peter J. Pronovost, MD, PhD; Laura L. Morlock, PhD; J. Bryan Sexton, PhD; Marlene R. Miller, MD, MSc; Christine G. Holzmueller, BLA; David A. Thompson,
U.S. Department of Health & Human Services May 7, 2014. New HHS Data Shows Major Strides Made in Patient Safety, Leading to Improved Care and Savings
U.S. Department of Health & Human Services May 7, 2014 New HHS Data Shows Major Strides Made in Patient Safety, Leading to Improved Care and Savings The data in this report shows a substantial nine percent
Errors in the Operating Room. Patrick E. Voight RN BSN MSA CNOR President Association of perioperative Registered Nurses (AORN)
Errors in the Operating Room Patrick E. Voight RN BSN MSA CNOR President Association of perioperative Registered Nurses (AORN) What What We All We Strive All Strive For: For: Patient Patient Safety Safety
UW Medicine Case Study
Learn Serve Lead April 2013 Association of American Medical Colleges ABOUT THE BEST PRACTICES FOR BETTER CARE CASE STUDY SERIES Better performers from the Best Practices for Better Care initiative, identified
Disclosing Medical Errors to Patients: International Developments and Future Directions
Disclosing Medical Errors to Patients: International Developments and Future Directions Thomas H. Gallagher, MD University of Washington School of Medicine Accelerating Interest in Disclosure Growing experimentation
Tom W. Reader, Rhona Flin and Brian H. Cuthbertson Communication skills and error in the intensive care unit
Tom W. Reader, Rhona Flin and Brian H. Cuthbertson Communication skills and error in the intensive care unit Article (Accepted version) (Refereed) Original citation: Reader, Tom W. and Flin, Rhona and
Hospital Administrative Staff vs. Nursing Staff Responses to the AHRQ Hospital Survey on Patient Safety Culture
Hospital Administrative Staff vs. Nursing Staff Responses to the AHRQ Hospital Survey on Patient Safety Culture Karen L. Hannah, MBA; Charles P. Schade, MD, MPH; David R. Lomely, BS; Patricia Ruddick,
Information Management and Continuity of Care Safe Practices (8-13)
Information Management and Continuity of Care Safe Practices (8-13) David Bates, MD David Classen, MD Charles Denham, MD Becky Martins October 12, 2007 This Webinar focuses upon the following NQF-EndorsedTM
Perspectives from the Field. Progress Toward Eliminating Healthcare-Associated Infections September 23-24, 2010 Arlington, VA
Perspectives from the Field Progress Toward Eliminating Healthcare-Associated Infections September 23-24, 2010 Arlington, VA Presentation Overview Linda Greene Association for Professionals in Infection
Electronic health records: underused in the ICU?
Electronic health records: underused in the ICU? Christopher W. Seymour, MD MSc Assistant Professor of Critical Care Medicine Core Faculty Member, CRISMA Center University of Pittsburgh School of Medicine
Implementation of the ABCDE Bundle: Results from a Real-World, Pragmatic Study Design. Andrew Masica, MD, MSCI Chief Clinical Effectiveness Officer
Implementation of the ABCDE Bundle: Results from a Real-World, Pragmatic Study Design Andrew Masica, MD, MSCI Chief Clinical Effectiveness Officer 0 Gap Between Knowledge and Delivery Translational Roadmap
A Comprehensive Unit-Based Safety Program (CUSP) in Surgery: Improving Quality Through Transparency
A Comprehensive Unit-Based Safety Program (CUSP) in Surgery: Improving Quality Through Transparency Michol Cooper, MD, PhD a, Martin A. Makary, MD, MPH b, * KEYWORDS Wrong site Wrong patient Universal
Breakdown 7/1/2011. JC Sentinel Events Context Patient Safety Concerns
JC Sentinel Events Context Patient Safety Concerns Team based Healthcare Delivery: Improving Patient Outcomes Brenda Zierler, PhD, RN Brian K. Ross, PhD, MD Institute for Simulation and Interprofessional
Appendix 1: Detailed Summary of Systematic Review
Appendix 1: Detailed Summary of Systematic Review Study, Feature Score,, Data Safety Improvement Cohort and Time Horizon for Main Outcome Measures and Case Adverse Drug Events (ADEs) Karnon 2009 [1] feature
Patient Safety Curriculum Florida State University College of Medicine
Patient Safety Curriculum Florida State University College of Medicine Dennis Tsilimingras, M.D., M.P.H. Director, Center on Patient Safety Assistant Professor of Family Medicine and Rural Health Florida
Speaker Profile Form
1 Speaker Profile Speaker Profile Form Name and Credentials: Patricia J. Posa RN, BSN, MSA Position Held: System Performance Improvement Leader Organization: St. Joseph Mercy Health System Business Address:
PPRNet Research Team. Objectives. Take home message. PPRNet QI Research 6/10/2008
Lynne S. Nemeth, PhD, RN Medical University of South Carolina PPRNet Research Team Ruth G. Jenkins, PhD Paul J. Nietert, PhD Andrea M. Wessell, PharmD Heather Liszka Rose, MD, MS Loraine F. Roylance, MA
Virtual Mentor American Medical Association Journal of Ethics January 2010, Volume 12, Number 1: 41-45.
Virtual Mentor American Medical Association Journal of Ethics January 2010, Volume 12, Number 1: 41-45. MEDICINE AND SOCIETY Gender Diversity and Nurse-Physician Relationships Beth Ulrich, EdD, RN You
Care Delivery Transformation in Academic Health Centers
Care Delivery Transformation in Academic Health Centers William B. Borden, MD Associate Professor of Medicine Director of Healthcare Delivery Transformation George Washington University Chest pain 67 year
Outline. Advanced Practice Providers in the Intensive Care Unit. Why utilize APPs in the ICU? 5/30/2013
Outline Advanced Practice Providers in the Intensive Care Unit Thomas Farley MS, NP Assistant Clinical Professor UCSF School of Nursing Why utilize APPs in the ICU Recent publications General review of
A MANAGER S GUIDE: HOW BETTER NURSE TO PATIENT RATIOS CAN IMPROVE THE HEALTH OF YOUR PATIENTS & LOWER STAFFING COSTS.
A MANAGER S GUIDE: HOW BETTER NURSE TO PATIENT RATIOS CAN IMPROVE THE HEALTH OF YOUR PATIENTS & LOWER STAFFING COSTS. RN-TO-PATIENT RATIOS & PATIENT SAFETY RN-to-Patient ratio is another key component
Public reporting improves healthcare. Jack Chen MBBS PhD MBA
Public reporting improves healthcare Jack Chen MBBS PhD MBA October 2010 BUREAU OF HEALTH INFORMATION PO Box 1770 Chatswood NSW 2057 Australia Telephone: +61 2 8644 2100 www.bhi.nsw.gov.au This work is
Chronic Critical Illness: Can it be prevented? Carmen C Polito, MD Pulmonary & Critical Care Medicine Emory University Atlanta, GA cpolito@emory.
Chronic Critical Illness: Can it be prevented? Carmen C Polito, MD Pulmonary & Critical Care Medicine Emory University Atlanta, GA cpolito@emory.edu Data free zone Disclosures A (Very) Old Case 65 year-old
Deborah Young, RN, BSN, CNOR Green Belt Charleston Area Medical Center
Deborah Young, RN, BSN, CNOR Green Belt Charleston Area Medical Center Charleston Area Medical Center Charleston, West Virginia 5,818 Employees 913 Licensed Beds 392 General Hospital 375 Memorial Hospital
REACHING ZERO DEFECTS IN CORE MEASURES. Mary Brady, RN, MS Ed, Senior Nursing Consultant, Healthcare Transformations LLC,
REACHING ZERO DEFECTS IN CORE MEASURES Mary Brady, RN, MS Ed, Senior Nursing Consultant, Healthcare Transformations LLC, 165 Lake Linden Dr., Bluffton SC 29910, 843-364-3408, marybrady6@gmail.com Primary
Overview of Lean at URMC
Overview of Lean at URMC Agenda Introduction to Lean at URMC Strategy for Lean at URMC Understanding Waste Introduction to Tools & Techniques 1 Healthcare, As It Is Currently Delivered in The US, is Unsustainable
Case Study Keeping the Commitment: Progress in Patient Safety
Case Study Keeping the Commitment: Progress in Patient Safety March 211 Johns Hopkins Medicine: Embedding Patient Safety in a University-Affiliated Integrated Health Care Delivery System Corrected May
Measuring and managing the economic impact of disruptive behaviors in the hospital
Enterprise Risk Management Measuring and managing the economic impact of disruptive behaviors in the hospital By Alan H. Rosenstein, MD, MBA Disruptive behaviors have been shown to have a significant negative
F.A.S.T. Family Activated Safety Team. A Rapid Response for Patient and Family Concerns
F.A.S.T. Family Activated Safety Team A Rapid Response for Patient and Family Concerns Ellen Noel MN,RN-BC Clinical Nurse Specialist Ellen.Noel@vmmc.org Overview What is F.A.S.T? Why do we need FAST? F.A.S.T.
What is Teamwork? Research Findings. Models of Team Performance Salas et al. What Teamwork IS and IS NOT (Salas et al)
Physician-Nurse Teamwork: The Patient Safety Solution Janet Nagamine, MD Tracy Scott, PhD Overview What is teamwork? Why teamwork? Outcomes data: patient, staff Barriers to teamwork Practical Solutions
University of Michigan Health System Program and Operations Analysis. Utilization of Nurse Practitioners in Neurosurgery.
University of Michigan Health System Program and Operations Analysis Utilization of Nurse Practitioners in Neurosurgery Final Report To: Laurie Hartman, Director of Advanced Practice Nurses, UMHS School
How To Educate Nursing Staff On Medication Reconciliation, Nurse Education, And
Advancing Medication Reconciliation in an Outpatient Internal Medicine Clinic through a Pharmacist-Led Educational Initiative Sarah M. Westberg, Pharm.D. 1 and Kathrine Beeksma, R.N. 2 1 College of Pharmacy
Not Just Another Checklist: Using Technology to Implement the Time- Out in the Non-OR Setting
Not Just Another Checklist: Using Technology to Implement the Time- Out in the Non-OR Setting Ross Ehrmantraut, RN, CCRN Patient Safety Officer Liz McNamara, RN, MN Clinical Operations Manager for Infection
North Carolina Prevent Catheter-Associated Bloodstream Infections (CLABSI): Targeting Zero Tool Kit Supplement
North Carolina Prevent Catheter-Associated Bloodstream Infections (CLABSI): Targeting Zero Tool Kit Supplement A Supplement to the National Stop BSI Campaign Toolkit http://www.onthecuspstophai.org/ Sponsored
ZERO By Chris Abe, RN, BSN, CIC, HEM; Jeanne Zack, PhD(c), RN, CIC; Stephen R. Lewis, MD; Tim Vanderveen, PharmD, MS
ZERO Photos courtesy of Cardinal Health By Chris Abe, RN, BSN, CIC, HEM; Jeanne Zack, PhD(c), RN, CIC; Stephen R. Lewis, MD; Tim Vanderveen, PharmD, MS 14 Patient Safety & Quality Healthcare November/December
Improving Patient Safety with Team Training
Improving Patient Safety with Team Training Amar P. Patel, MS, NREMT-P, CFC Manager, Medical Simulation Center http://www.wakemed.org/landing.cfm?id=1097&otopid=616 WakeMed Health & Hospitals Raleigh,
Summary of Infection Prevention and Control Program Assessment. Prepared for: The Delaware Health and Social Services Division of Public Health
AZ Saving Lives Reducing Risk Protecting Your Bottom Line Summary of Infection Prevention and Control Program Assessment Introduction/Background Prepared for: The Delaware Health and Social Services Division
Raoult Ratard, MD, MS, MPH Louisiana State Epidemiologist. Debra Rushing, RN, MBA/HCM, CPE Executive Director eqhealth Solutions Louisiana
Raoult Ratard, MD, MS, MPH Louisiana State Epidemiologist Debra Rushing, RN, MBA/HCM, CPE Executive Director eqhealth Solutions Louisiana Erica Washington, MPH Healthcare-Associated Infections Coordinator
Surgical Communication Breakdown - A Risk to Patients
Patterns of Communication Breakdowns Resulting in Injury to Surgical Patients Caprice C Greenberg, MD, MPH, Scott E Regenbogen, MD, David M Studdert, LLB, SCD, MPH, Stuart R Lipsitz, SCD, Selwyn O Rogers,
Welcome! Limited dial-in lines are available. Please send a chat message if needed. This event is being recorded.
Welcome! Audio for this event is available via ReadyTalk Internet Streaming. No telephone line is required. Computer speakers or headphones are necessary to listen to streaming audio. Limited dial-in lines
Disclosing Medical Errors: 2008 and Beyond. Wendy Levinson, MD Professor of Medicine University of Toronto
Disclosing Medical Errors: 2008 and Beyond Wendy Levinson, MD Professor of Medicine University of Toronto Goals 1. To describe physicians attitudes and experience re disclosure. 2. To describe changing
History, Credentials, Teamwork
History, Credentials, Teamwork Risk Management evolved from insurance management Called Risk Management because involves more than just insurance Healthcare Risk Management began mid 1970 s Medical malpractice
Saving lives in Surgery
A Guide for Chief Executives in implementing the Surgical Safety Checklist Why this matters Within health care we now have a term for those events that should never happen, can have catastrophic consequences
Principles of Patient Safety An Overview
Principles of Patient Safety An Overview Richard T. Griffey, MD, MPH Assistant Professor, Emergency Medicine Mary Z. Taylor, JD Director of Patient Safety Washington University School of Medicine 1 Learning
2014 Northern New England Regional Survey of Healthcare Professionals Continuing Education Needs: Review of Results
2014 Northern New England Regional Survey of Healthcare Professionals Continuing Education Needs: Review of Results Mary G. Turco, EdD Assistant Professor of Medicine, Geisel School of Medicine at Dartmouth
Standards of Practice for Patient Identification, Correct Surgery Site and Correct Surgical Procedure
Standards of Practice for Patient Identification, Correct Surgery Site and Correct Surgical Procedure Introduction The following Standards of Practice were researched and written by the AST Education and
Health System Strategies to Improve Chronic Disease Management and Prevention: What Works?
Health System Strategies to Improve Chronic Disease Management and Prevention: What Works? Michele Heisler, MD, MPA VA Center for Clinical Practice Management Research University of Michigan Department
Patient Experience. The Cleveland Clinic Journey. American Medical Group Association Orlando, Florida March 14, 2013
Patient Experience The Cleveland Clinic Journey American Medical Group Association Orlando, Florida March 14, 2013 James Merlino, MD Chief Experience Officer Overview How did Cleveland Clinic change their
Goals of Presentations. The Rehab Team Do We Need a Recharge? Recharging the Rehab Team: Strategies to Improve Team Care and Patient Outcomes
Recharging the Rehab Team: Strategies to Improve Team Care and Patient Outcomes UDSMR Annual Conference - Thursday August 8, 2013 DALE STRASSER, MD ASSOC. PROFESSOR, REHABILITATION MEDICINE EMORY UNIVERSITY,
St. Joseph Hospital. Transforming The Culture of Safety Through Teamwork and Communication. Objectives for Today
Transforming The Culture of Safety Through Teamwork and Communication Ray Casciari, MD Chief Medical Officer Mary Ann Vincent, RN, MBA Vice President Quality & Safety Tina Retrosi, RN, BSN Patient Safety
Stacy McLaughlin, RN, MSN. Director of Quality & Performance Improvement
Stacy McLaughlin, RN, MSN Director of Quality & Performance Improvement 25-bed CAH 21 beds: acute / observation / swingbed 4 bed ICU ED volumes: 14,400 encounters/year 5 Clinics: Rural Health / Primary
Helen Peake-Godin MN RN University of Southern Maine College of Science, Technology, and Health School of Nursing
Helen Peake-Godin MN RN University of Southern Maine College of Science, Technology, and Health School of Nursing History of Sagamore Village Health Center Brief Overview The Sagamore Health Center, developed
Integrating Defensive Monitoring in the General Care Unit to Improve Failure to Rescue Trends
Integrating Defensive Monitoring in the General Care Unit to Improve Failure to Rescue Trends February 2009 Author: Susan Bruey, RN BSEd MSN Contents Introduction.... 2 The Problem Acknowledged.... 3 Current
Using Six Sigma Methodology to Improve Handoff Communication in High-Risk Patients
Using Six Sigma Methodology to Improve Handoff Communication in High-Risk Patients Kshitij P. Mistry MD, MSc; James Jaggers, MD; Andrew J. Lodge, MD; Michael Alton, MSN, RN; Jane M. Mericle, BSN, RN, MHS-CL;
IMPROVING DIAGNOSIS & REDUCING DIAGNOSTIC ERRORS: AN EMERGING NATIONAL PATIENT SAFETY PRIORITY
IMPROVING DIAGNOSIS & REDUCING DIAGNOSTIC ERRORS: AN EMERGING NATIONAL PATIENT SAFETY PRIORITY HARDEEP SINGH, MD, MPH HOUSTON VETERANS AFFAIRS CENTER FOR INNOVATIONS IN QUALITY, EFFECTIVENESS & SAFETY
Changing the culture of any organization is well known to be a long process,
Creative Nursing, Volume 18, Issue 4, 2012 Impact of Unit Practice Councils on Culture and Outcomes Susan Wessel, MS, MBA, RN, NEA-BC This article describes positive outcomes in culture, Hospital Consumer
The Hospital Elder Life Program (HELP): Resources for Implementation
The Hospital Elder Life Program (HELP): Resources for Implementation Sharon K. Inouye, M.D., M.P.H. Professor of Medicine Beth Israel Deaconess Medical Center Harvard Medical School Milton and Shirley
Patient Safety; Hospital Risk. Perspectives of Hospital C-Suite and Risk Managers. April 2013. www.aig.com/us/prevention
Patient Safety; Hospital Risk Perspectives of Hospital and Risk Managers April 2013 www.aig.com/us/prevention Introduction AIG s experience as a risk management partner to over 2,000 hospitals around the
THE ENORMOUS COST OF MEDICAL ERRORS
Allied Academies International Conference page 27 THE ENORMOUS COST OF MEDICAL ERRORS Michele McGowan, King s College Bernard J Healey, King s College ABSTRACT The Institute of Medicine (1999) reports
Why are QI methods needed?
Quality Improvement for ICU Rehab, Sedation & Delirium Why are QI methods needed? Dale M. Needham, MD, PhD Professor, Pulmonary & Critical Care, and Physical Med & Rehab Dale.Needham@jhmi.edu @DrDaleNeedham
Patient Safety: Applying Industrial Quality Models in Healthcare Settings Tempora mutantur, nos et mutamur in illis
Patient Safety: Applying Industrial Quality Models in Healthcare Settings Tempora mutantur, nos et mutamur in illis Julie Louise Gerberding, MD MPH Division of Healthcare Quality Promotion National Center
Evidence-Based Design Accreditation and Certification (EDAC) CEU Form
EDAC Certified Individuals, please complete your form fully and carefully. Retain this copy for your records. You will need this to submit courses through Castle Worldwide, Inc. when you are due for renewal.
Application of Engineering Principles to Patient Flow & Healthcare Delivery
Application of Engineering Principles to Patient Flow & Healthcare Delivery Jeanne M Huddleston, MD, MS Medical Director, Health Care Systems Engineering Mayo Clinic 2013 MFMER slide-1 2013 MFMER slide-2
Engaging Nurses in Practice WHA Nurse Leader Forum May 2010
Engaging Nurses in Practice WHA Nurse Leader Forum May 2010 Ruth Risley-Gray, RN, BSN, MHA, CPHQ Director Patient Services & Quality Chief Nursing Officer Langlade Hospital About Langlade Religious Hospitallers
Medication Management (Safe Practices 14-18)
Medication Management (Safe Practices 14-18) David Bates, MD Hayley Burgess, PharmD Charles Denham, MD November 8, 2007 This Webinar focuses upon the following NQF-EndorsedTM Safe Practices: Safe Practice
THE EFFECTS OF NURSE EDUCATION AND CERTIFICATION ON HOSPITAL- ACQUIRED INFECTIONS
THE EFFECTS OF NURSE EDUCATION AND CERTIFICATION ON HOSPITAL- ACQUIRED INFECTIONS Cassi Welch, BSN Honors Student Faculty Mentor: Emily Cramer, PhD Submitted to the University of Kansas School of Nursing
Glossary of Health Coverage and Medical Terms
Glossary of Health Coverage and Medical Terms This glossary defines many commonly used terms, but isn t a full list. These glossary terms and definitions are intended to be educational and may be different
Nursing Quality: Measurement and Improvement
Nursing Quality: Measurement and Improvement This self-directed learning module contains information you are expected to know to protect yourself, our patients, and our guests. Target Audience: CMC and
What is Palliative Care
What is Palliative Care Maine Quality Counts Portland Regional Forum Isabella N. Stumpf, DO Division Director, Palliative Medicine, Maine Medical Center Medical Director, Palliative Care, MaineHealth Disclosure
Just Culture: The Key to Quality and Safety
Just Culture: The Key to Quality and Safety Gregg S. Meyer, MD, MSc Edward P. Lawrence Center for Quality and Safety, MGH/MGPO COE September 2010 Agenda The Need for a New Approach The Just Culture Model
CLABSI Experience Saint Louis University Hospital
CLABSI Experience Saint Louis University Hospital Thursday, September, 01 Our Story Academic medical center Owned by Tenet Healthcare affiliated with Saint Louis University (SLU) and a closed medical staff
Figure 1. The challenge confronting U.S. Health Care Spending, Quality -- and the Health of the Public
Figure 1. The challenge confronting U.S. Health Care Spending, Quality -- and the Health of the Public Medicare spending per enrollee (2003) Red dots indicate Wisconsin and Minnesota HRRs 12,000 Medicare
INSTRUCTIONS Monitoring Progress for Sustainable Improvement
INSTRUCTIONS Monitoring Progress for Sustainable Improvement What is this tool? This tool provides guidance on how to monitor and report your progress in sustaining performance improvements, including