2010 Northwest Patient Safety Conference

Thanks to the 230+ attendees from over 67 organizations across the Northwest who joined us for our seventh regional conference held at the Hilton Seattle Airport & Conference Center on May 4, 2010, which focused on the topic of “Patient Safety Culture.” Presentations and small-group discussions in workshop formats provided a full-day event that challenged participants’ assumptions about best practices, and provided tools and methods that can be quickly put to use in participants’ care settings. Topics covered a wide range from root cause analyses to what we’re learning from Washington’s mandatory reporting programs; and included Qualis Health’s annual awards presentations, a poster session, networking opportunities, and much, much more…

• Agenda (Click to download a PDF of the day’s full agenda)

Keynote Speaker: We joined with the Foundation’s Surgical Care and Outcomes Assessment Program(SCOAP) to hear from surgeon and writer, Atul Gawande, MD, MPH, a staff member of Brigham and Women’s Hospital, the Dana Farber Cancer Institute, and the New Yorker magazine. His book Better: A Surgeon’s Notes On Performance is a New York Times bestseller and one of Amazon.com’s ten best books of 2007. His newest book, The Checklist Manifesto, is one of Amazon’s best books of the month: December 2009. Plenary Speakers: Mick Oreskovich, MD, is Medical Director and Chief Executive Officer of Washington Physicians Health Program, whose mission is to facilitate the rehabilitation of healthcare practitioners who have physical or mental conditions that could compromise public safety and to monitor their recovery. He provides leadership and oversight over all clinical and administrative operations. David Marx, JD, is President of Outcome Engineering, a Dallas-based risk management firm, which currently spends the majority of its effort on helping high-risk organizations develop safety supportive practices and culture. David began his career as a Boeing aircraft design engineer. In his final years at Boeing, David organized a human factors and safety group where his team won the International Whittle Award for the development of a human error investigation process now used by air carriers around the world. He has served as an advisor to the Federal Aviation Administration’s Human Factors Research Program and to the NASA Space Shuttle Program. David was the principal consultant to guide the State of Oregon and the Oregon Health Care Association to build the first state-wide, quantitative model of medication safety risk. In the area of safety culture, David authored for the National Institutes of Health the document “Patient Safety and the ‘Just Culture’: A Primer for Healthcare Executives.” In November 2005, David’s firm launched the Just Culture Community, a web-based resource for organizations on the journey to more open learning cultures. In December 2005, the Institute for Safe Medication Practices awarded David the Cheers award for his work in developing the “Just Culture.”

Patient Safety and the Just Culture: Checklists, Perfection, and our Inescapable Human Fallibility

Selected Sessions ABCs of Root Cause Analyses – Helen Harte, RN, MPH, MPA, Director of Quality (Community Health Plan of WA) explored the process of root cause analyses using the VA method, which is appropriate for all care settings. Virginia Mason Medical Center’s “Medical Home”: A team approach to safe and reliable patient care (1.8MB PDF) – Ingrid Gerbino, MD discussed the development of a primary care delivery system that meets patients’ needs by providing them with a medical home, including how VMMC worked with a large employer group and its payer to develop an “Ambulatory Intensive Care Unit.” Handoffs: A Critical Communication Process – Kathlyn Springer (The Doctors Company) helped participants learn to recognize the potential for common errors across settings and become familiar with solutions and methods for improvement.

The Washington Patient Safety Coalition and its planning partners, the Oregon Patient Safety Commission, the Washington State Association for Healthcare Quality, and the Oregon Association for Healthcare Quality would like to thank the 120+ attendees who joined us for our first cross-border regional conference, held April 6, 2010 at the Doubletree Hotel Portland-Lloyd Center in Portland, Oregon. This conference focused on a single important issue often overlooked by our colleagues — “safe care of the very large patient.” Keynote Speaker: Keith Bachman, MD, FACP, is the Clinical Lead for Kaiser Permanente’s Care Management Institute Weight Management Initiative. In the Kaiser Permanente Northwest region, he is the physician lead for weight management and obesity prevention activities. He is also a consultant to the Severe Obesity/Bariatric Surgery program and maintains a primary care internal medicine practice.

Weight, Weight Bias, and Obesity: The challenge of obesity in the healthcare system

Selected presentations and Additional Materials: Other featured topics included surgery-related challenges, preventing injury to staff, maintaining skin integrity across care settings, and optimizing care transitions in the community. This activity has been approved by the National Association for Healthcare Quality for 6.6 CPHQ CE hours. Safe Care of the Obese Surgical Patient (5 MB PDF) – Clifford W. Deveney, MD (Oregon Health and Science University, Portland) Have you read this JAMA article on “Quality of Care Among Obese Patients“? In 2007, the Oregon IHI Network and the Oregon leadership of the Advancing Excellence in America’s Nursing Homes campaign formed a Joint Committee to plan and develop cross-setting interventions for transitional care, with an initial focus on pressure ulcers. They developed a Transitional Care & Pressure Ulcers Project Toolkit and other resources.

2009 Northwest Patient Safety Conference

The Coalition’s Steering Committee would like to thank the 215 attendees who joined us from over 65 organizations across the Northwest at our sixth regional conference at the Hilton Seattle Airport & Conference Center which focused on keeping our patients safe throughout their journey of care from home through outpatient, inpatient, and continuing care settings. The conference was organized around the themes of communication, medication safety, preventing infection,and safe procedural care. Presentations and small-group discussions in workshop formats provided a full-day event that challenged participants’ assumptions about best practices, and provided tools and methods that can be quickly put to use in participants’ care settings.

Agenda

Keynote/Plenary Session Speakers: Robert M. Wachter, MD is Professor and Associate Chairman of the Department of Medicine at the University of California, San Francisco. He is also Chief of the Division of Hospital Medicine, and Chief of the Medical Service at UCSF Medical Center. He has published 200 articles and 6 books in the fields of quality, safety, and health policy and edits the federal government’s two leading patient safety websites. He coined the term “hospitalist” in a 1996 New England Journal of Medicine article, served as the first elected president of the Society of Hospital Medicine, and edits the field’s main textbook, Hospital Medicine.

Creating ‘Accountability’ in a ‘No Blame’ Culture: The Yin and Yang of the Quality and Safety Revolutions

Gail Nielsen is the Iowa Health System Clinical Performance Improvement Education administrator. She is a nationally known lecturer and facilitator on the topics of leadership in the spread of performance improvement, health literacy, patient-centered care, and redesigning the discharge process. While a George H. Merck Scholar at the Institute for Healthcare Improvement she was a key member of IHI’s work on patient-centered care and Transforming Care at the Bedside.

Health Literacy as a Philosophy of Care

Daniel O’Connell, PhD, is a nationally-recognized speaker who has worked as an educator, consultant, clinician, department chair and executive director in medical, behavorial health and educational settings the past 30 years. He is a consultant toThe Institute for Healthcare Communication and serves on the faculty of theFoundation for Medical Excellence. He teaches in the Residency Programs at the University of Washington School of Medicine and maintains a coaching and consulting practice working primarily with health organizations and individual providers on all aspects of the pscyhology of medicine, leadership in healthcare settings and professional interactions.

Bad behavior — preparing for and dealing with disruptive behavior by providers Breakout Session: Disclosing Adverse Outcomes and Medical Errors

Selected Sessions Family-activated rapid response teams– Ellen Noel, MN shared how Virginia Mason Medical Center used Lean methods to develop a family-activated system to enhance safety, the evaluation metrics used, and learnings gained.

Virginia Mason’s F.A.S.T. Brochure

The Medication Safety Journey– Natasha Nicol, PharmD, FASHP from Cardinal Health discussed how to design a sustainable culture of safety; how to collect medication errors and use that information to affect true change; and using the IHI Global Trigger Tool to determine level of harm. Surgical Quality in Washington State and the Successful implementation of Operating Room Checklists– E. Patchen Dellinger, MD presented how the University of Washington has overcome barriers to implement the World Health Organization-endorsed checklists, and his subsequent work with the Foundation’sSurgical Care and Outcomes Assessment Program (SCOAP) to spread the initiative to every OR in Washington. 2009 Qualis Health Awards of Excellence in Healthcare Quality

2008 Northwest Patient Safety Conference

The Coalition’s Steering Committee would like to thank the 300+ attendees who joined us from over 80 organizations across the Northwest at this year’s conference at the Hilton Seattle Airport & Conference Center which explored the significance of transitions at several levels: As a maturing health care movement, what has patient safety accomplished, and how must it change to address both continuing and new challenges? What will it take to achieve significant and lasting improvement, and what lies ahead? Patients move through multiple transitions in care – changes in levels of care, providers, physical location. We will hear specific examples of how safety can be optimized throughout many types of transitions.

Agenda (click to download PDF)

Keynote/Plenary Session Speakers Lucian Leape, MD, Adjunct Professor of Health Policy in the School of Public Health at Harvard, is internationally recognized as a leader of the patient safety movement, starting with the publication in JAMA of his seminal article, Error in Medicine, in 1994. His subsequent research demonstrated the success of the application of systems theory to the prevention of adverse drug events. In addition, he has directed research into overuse and underuse of cardiovascular procedures. He has published over 100 papers on patient safety and quality of care.

“Are We Safer Yet?”

Eric Coleman, MD, MPH, Associate Professor of Medicine at the University of Colorado, is the Director of the Care Transitions Program, aimed at improving quality and safety during times of care “hand-offs”. He is also the Executive Director of the Practice Change Fellows Program, designed to build leadership capacity among health care professionals who are responsible for geriatric programs and service lines.

“Listen to Your Patients – They are Telling You How to Improve Their Care Transitions”

Selected Sessions “Checking Safety in the Operating Room”– David Flum, MD presented how aviation-type OR safety checklists have been developed by the World Health Organization (WHO) and how the UWMC and other Washington Hospitals are building on this approach through the Foundation for Health Care Quality’s SCOAP Program. WHO’s “Safe Surgery Saves Lives” initiative launched at an event in Washington, D.C. on June 25.

2007 Northwest Patient Safety Conference

Featured Keynote and Plenary Session Speakers: Don Berwick, MD, MPP, President, CEO, and Co-founder of the Institute for Healthcare Improvement (IHI) in Boston, an internationally recognized expert on health care quality improvement; and Michael Leonard, MD, the national physician leader for Patient Safety for Kaiser Permanente.