25 years of “ah-ha” moments. experience the collective impact
Transcription
25 years of “ah-ha” moments. experience the collective impact
The 25th Annual IHI National Forum on Quality Improvement in Health Care December 8-11, 2013 Orlando, FL • 25 years of “ah-ha” moments. experience the collective impact. National Forum T R Y I T F R E E AT W W W. D E B M E D. C O M THINGS CHANGE. FOR GOOD REASON. I F Y O U ’ R E S T I L L U S I N G D I R E C T O B S E R VAT I O N T O C A L C U L AT E H A N D H Y G I E N E C O M P L I A N C E , T H E R E ’ S A B E T T E R W A Y. Hand hygiene is a key component of reducing infections as part of an overall patient safety and quality program. The most effective, proven and affordable solution on the market, the DebMed® GMSTM Group Monitoring System can help you lead the change to electronic monitoring at your hospital. Stop by the DebMed® Booth, #1107 and register to win $500 Visa gift card. Antiquated Methods. Unreliable Data. Lead the Change Dear Colleagues, Wow—25 National Forums. A quarter century of improving care for patients, together. It’s almost hard to believe. So much has changed! I remember when cataract surgery meant a seven-day hospital stay, with the patient immobilized by sandbags and restricted to a liquid diet. Now it’s a simple outpatient procedure, often with the family watching in the room. We’ve gone from improving individual practices and units to improving whole systems; from care for individuals to care for populations; and, most importantly, from caring for patients to caring with patients. We are now co-producers of care—active partners working with patients to improve care and health. I’m confident that, thanks to the extraordinary effort, dedication, and passion from all of you and your colleagues, health care today is better and safer. And perhaps for the first time, there is universal commitment to reducing the costs of care. IHI’s Triple Aim has provided a holistic framework for improvement to professionals and organizations around the world. We’re tearing down silos and bridging chasms. We have come a long way, and achieved so much together. But I know you’ll agree that we have much more work to do. For 25 years, the National Forum has been the place to convene and learn about what works in health care improvement. It’s been the place to find the latest innovations and connect with the most inspiring leaders. Twenty-five National Forums have taught us what works, and now we need to spread what works everywhere, so all patients will benefit. We can do this, together. That’s what this National Forum is about—collective impact. We’re seeing how collective impact happens on a small scale. The revolution of carefully coordinated care is improving patients’ experiences and outcomes everywhere. Multidisciplinary teams are streamlining processes, removing barriers to effective communication and cooperation, and creating new models of care every day. Now we need to go bigger. IHI’s work on the Triple Aim in communities; our work to bring employers, providers, and health plans together to improve health and reduce costs; our work to ensure that everyone has “the conversation” about end-of-life care—these are examples of the power and promise of collective impact. Almost 10 years after we launched the 100,000 Lives Campaign, I’m still asked to speak about it. People everywhere are still keenly interested in how to bring disparate groups of people together around a common goal, and then achieve that goal. IHI was only about 50 people back then. I’m sure some thought we were crazy to start a national patient safety campaign. But there’s a famous quote that inspired us then and sustains us now —it’s printed on a wall outside my office—“Never doubt that a small group of thoughtful, committed citizens can change the world. Indeed, it is the only thing that ever has.” At this National Forum, we want to hear from you as we plan our next big initiative: A global collaborative to transform care and health worldwide. It might seem strange to think of the thousands gathered here this week as a “small group,” but you represent tens of millions of health professionals around the world. You are the small group of thoughtful, committed citizens that will have a collective impact, improving the health and lives of patients and families everywhere. Enjoy the National Forum. Sincerely, table of Contents Agenda-at-a-Glance......................................... 2 Keynotes............................................................ 6 Special Interest Keynotes.................................. 7 Sunday, December 8 Learning Labs................................................... 8 Monday, December 9 Forum Excursions............................................ 13 Virtual Site Visits............................................ 14 Scientific Symposium...................................... 15 Minicourses..................................................... 16 Welcome Reception......................................... 20 Student and Faculty Reception ...................... 20 Tuesday, December 10 25th National Forum Celebration...................... 5 Keynote One: Maureen Bisognano................... 21 Workshops A and B ......................................... 22 Keynote Two: Eric Weihenmayer....................... 24 Workshop C .................................................... 26 Storyboard Reception...................................... 48 Wednesday, December 11 Special Interest Breakfasts .............................32 Keynote Three: Dr. Nancy Snyderman & Lindsay Beck ...........33 Workshops D and E .........................................33 Keynote Four: Dr. Donald Berwick ....................36 IHI Onsite App Instructions .............................. 4 Networking Events............................................ 4 Post-Conference Recordings............................. 5 Shuttle Map.................................................... 38 Conference Map ............................................. 40 Conference Information ................................. 43 Exhibit Hall Floor Plan .................................... 46 Continuing Education .................................... 47 Storyboards .................................................... 48 Index by Presenter .......................................... .58 Exhibitors ....................................................... 60 Maureen Bisognano President and CEO, Institute for Healthcare Improvement Welcome! Tweet using #IHI25Forum 1 Forum Agenda at a glance 7:00 AM Pre-Conference 8:00 AM 9:00 AM 10:00 AM 11:00 AM 12:00 PM 7:00 AM – 5:30 PM Registration Open 11:00 AM –12:00 PM National Forum Orientation Crystal Ballroom, Salon G Sunday DECEMBER 8 Pre-Conference Monday 6:30 AM – 5:30 PM Registration Open 7:00 AM – 8:00 AM National Forum Orientation and Continental Breakfast* 8:30 AM – 4:00 PM Minicourses (lunch provided) Crystal Ballroom, Salon G 8:30 AM – 5:00 PM Forum Excursions (lunch provided) Departing from the G Gaylord Palms DECEMBER 9 8:30 AM – 4:30 PM Virtual Site Visits (lunch provided) 8:30 AM – 5:00 PM Scientific Symposium (lunch provided) Sun Ballroom A * Breakfast provided for Minicourse, Virtual Site Visit, Forum Excursion, and Scientific Symposium attendees Conference DAY 1 Tuesday DECEMBER 10 6:30 AM – 5:30 PM Registration Open 7:00 AM – 8:00 AM National Forum Orientation and Continental Breakfast Crystal Ballroom, Salon G 8:00 AM – 9:00 AM Keynote One: Maureen Bisognano Cypress Ballroom 3 9:30 AM – 2:45 PM CEO and Leadership Summit Grand Ballroom, Salon 8 9:30 AM – 10:45 AM Workshop A 10:30 AM – 1:30 PM Exhibit Hall Open Palms Ballroom 11:15 AM – 12:30 PM Workshop B (repeat of Workshop A) Conference Day 2 6:30 AM – 1:30 PM Registration Open 7:00 AM – 8:00 AM Continental Breakfast Wednesday DECEMBER 11 2 7:00 AM – 7:45 AM Special Interest Breakfasts 8:00 AM – 9:00 AM Keynote Three: Dr. Nancy Snyderman and Lindsay Beck 10:30 AM – 1:30 PM Exhibit Hall Open Palms Ballroom 9:30 AM – 10:45 AM Workshop D Cypress Ballroom 3 25th Annual National Forum on Quality Improvement in Health Care 11:15 AM – 12:30 PM Workshop E (repeat of Workshop D) 1:00 PM 2:00 PM 3:00 PM 4:00 PM 5:00 PM 6:00 PM 7:00 PM 5:00 PM – 7:00 PM International Attendees Meeting 1:00 PM – 4:30 PM Learning Labs Crystal Ballroom, Salon D 4:30 PM – 7:30 PM 6th Annual Open School Chapter Congress Sponsored by Kaiser Permanente 7:00 PM – 9:00 PM Faculty and Student Reception Resort and Convention Center 3:30 PM – 6:30 PM Welcome Reception Palms Ballroom G Gaylord Palms, Emerald Bay Plaza 3:15 PM – 4:15 PM Keynote Two: Eric Weihenmayer 12:30 PM – 1:30 PM Lunch 1:30 PM – 2:45 PM Workshop C Cypress Ballroom 3 4:15 PM – 6:30 PM Exhibit Hall Open Palms Ballroom 4:30 PM – 6:30 PM Storyboard Reception Palms Ballroom 6:30 PM – 10:00 PM 25th National Forum Celebration Pool Pavilion STAY CONNECTED 12:30 PM – 1:30 PM 1:30 PM – 2:30 PM Lunch Keynote Four: Dr. Donald Berwick Stay connected with IHI and your fellow National Forum attendees! Use the hashtag #IHI25Forum when tweeting. Be sure to follow IHI on Twitter, Facebook, LinkedIn, and our IHI blogs. Cypress Ballroom 3 Welcome! Tweet using #IHI25Forum 3 Forum App: IHI ONSITE IHI Forum App for All Smartphones: IHI Onsite The IHI Forum app (IHI Onsite) serves as your all-in-one event guide by putting everything you need to know right onto your mobile device. Networking Events The IHI National Forum provides many networking opportunities including during lunches, breaks, and receptions, while doing yoga, and on Twitter using #IHI25Forum. The IHI Forum app will enable you to: Don’t miss these networking events: • Browse all of the National Forum session descriptions (including Learning Labs, Minicourses, General Conference workshops, etc) Welcome Reception • Take notes in sessions that will be saved to your IHI profile • Browse full faculty biographies • See Twitter updates using the conference hash tag #IHI25Forum • Locate events and rooms using an interactive map of the Marriott space • Check out exhibitor descriptions and booth locations Monday, December 9 3:30 PM – 6:30 PM Exhibit Hall - Palms Ballroom Complimentary Yoga Tuesday, December 10 6:00 AM – 7:00 AM Key Largo Social Media 101 Lunch n’ Learn Tuesday, December 10 12:40 PM – 1:20 PM Grand Ballroom, Salon 7 The IHI Forum app is available for free in the App Store and Android Market. Search either store for “IHI Onsite” and download yours today. Once you have downloaded the IHI Onsite app: Tuesday, December 10 12:40 PM – 1:20 PM Crystal Ballroom, Salon H Storyboard Reception • Ensure you are connected to the internet Tuesday, December 10 4:30 PM – 6:30 PM • Launch the app Exhibit Hall - Palms Ballroom • Enter your last name as your username NEW! 25th National Forum Celebration • Enter your order ID for this event as your password (available under the bar code on your name badge — the numbers after and not including OID) Pavilion Pool • Click “Verify” For help with the IHI app, please ask any IHI Blue Shirt. 4 Be the Change: Three Things Needed to Achieve Health Equity Tuesday, December 10 6:30 PM – 10:00 PM Join us to celebrate 25 years of health care improvement and toast the good work yet to come. Special Interest Breakfasts Wednesday, December 11 7:00 AM – 7:45 AM See page 32 for details and locations. 25th Annual National Forum on Quality Improvement in Health Care 25 National Forum Celebration th National Forum Tuesday, December 10 6:30 PM – 10:00 PM Pool Pavilion Join us by the Marriott pool to celebrate 25 years of health care improvement. We’ll provide food, drinks, and entertainment (including an a capella group and dueling pianos!) This event is free of charge. Post-National Forum Recordings If you attended the National Forum General Conference in person, in January you will receive: • FREE audio synced with PowerPoint slides for every General Conference workshop • FREE videos of keynote and special interest keynote presentations Registered attendees will receive an email from IHI in January with instructions on how to access the recordings and videos. 5 KEYNOTES Keynote One: Maureen Bisognano Tuesday, December 10 • 8:00 AM – 9:00 AM Cypress Ballroom 3 Maureen Bisognano, President and CEO, Institute for Healthcare Improvement (IHI), is a prominent authority on improving health care systems, whose expertise has been recognized by her elected membership to the Institute of Medicine and by her appointment to The Commonwealth Fund’s Commission on a High Performance Health System, among other distinctions. Ms. Bisognano advises health care leaders around the world, is a frequent speaker at major health care conferences on quality improvement, and is a tireless advocate for change. She is also an Instructor of Medicine at Harvard Medical School and a Research Associate in the Brigham and Women’s Hospital Division of Social Medicine and Health Inequalities. Prior to joining IHI, she served as CEO of the Massachusetts Respiratory Hospital and Senior Vice President of the Juran Institute. Keynote Two: Erik Weihenmayer Tuesday, December 10 • 3:15 PM – 4:15 PM Cypress Ballroom 3 Erik Weihenmayer is one of the most inspiring, engaging, and sought after speakers in the world. Despite losing his vision at age 13, Erik has become an accomplished mountain climber, paraglider, skier, and kayaker who never let blindness interfere with his passion for an exhilarating and fulfilling life. Erik’s powerful message speaks to harnessing the power of adversity and using it as fuel for greatness. He sees every new challenge as an opportunity to problem solve, strategize, and create a new way forward. Citing stories from his thrilling journeys, Erik’s presentations embrace a passion for discovery and innovation. He believes in being a pioneer, in making the impossible possible, and opening up a new world of opportunity for yourself, your organization, and your team. His accomplishments show that one does not have to have perfect eyesight to have extraordinary vision. In May 2001, Erik Weihenmayer became the only blind person in history to reach the summit of Mount Everest, and in 2008, he completed his quest to climb the Seven Summits—the highest mountain on each continent. Additionally, he has ascended dozens of major peaks, rock walls, and ice climbs around the planet. These include the first blind ascent of the 2,900-foot Nose of El Capitan in Yosemite, a difficult alpine climb of the spectacular 19,511-foot Alpamayo in Peru, and an ascent of a rarely climbed 3,000 foot frozen waterfall in Nepal. Keynote Three: P Nancy Snyderman, MD, and Lindsay Nohr Beck Wednesday, December 11 • 8:00 AM – 9:00 AM Cypress Ballroom 3 Nancy Snyderman, MD, is Chief Medical Editor of NBC News. Dr. Nancy Snyderman joined NBC News as the Chief Medical Editor in 2006. Her reports appear on Today, NBC Nightly News with Brian Williams, Dateline NBC, and MSNBC. She has reported on a wide range of medical topics and has travelled the world extensively, reporting from many of the world’s most troubled areas. Dr. Snyderman is a fully trained pediatric otolaryngologist and currently remains on the staff of the Department of Otolaryngology-Head and Neck Surgery at the University of Pennsylvania. Dr. Snyderman’s medical work has been widely published in peer review journals, and she is the recipient of numerous research grants as well as awards for her 6 broadcasting work. She is the author of Medical Myths That Can Kill You, among other publications, and she writes a monthly column for Good Housekeeping magazine. Lindsay Nohr Beck is a respected patient advocate most well known for her work in oncology. She currently consults for several non-profit and for-profit companies based on her resounding success as the visionary leader of Fertile Hope. Most recently, Lindsay served as a Cancer & Fertility Advisor for the LIVESTRONG Foundation where she led a groundbreaking initiative with major insurance providers to reform health care benefits for cancer patients. Lindsay joined LIVESTRONG after the organization acquired Fertile Hope, the company that she founded to address the profound reproductive needs of cancer patients and survivors—a need she discovered after her own experience with recurrent tongue cancer in her early 20s. Under Lindsay’s leadership, Fertile Hope strategically integrated two disparate medical specialties by changing the standard of care and catalyzing the establishment of a new medical discipline now called “oncofertility.” She has co-authored several papers on the subject, most notably ASCO’s Fertility Preservation Guideline, presented extensively around the world, and appeared in numerous media outlets, including the TODAY show, Wall Street Journal, New York Times, and SELF magazine. Additionally, she is the co-author of 100 Questions & Answers About Cancer and Fertility. Keynote Four: Donald M. Berwick, MD, MPP Wednesday, December 11 • 1:30 PM – 2:30 PM Cypress Ballroom 3 Donald Berwick, MD, MPP, is President Emeritus and Senior Fellow at the Institute for Healthcare Improvement (IHI), an organization that Dr. Berwick co-founded and led as President and CEO for 18 years. He is one of the nation’s leading authorities on health care quality and improvement. In July, 2010, President Obama appointed Dr. Berwick to the position of Administrator of the Centers for Medicare and Medicaid Services (CMS), which he held until December, 2011. A pediatrician by background, Dr. Berwick has served as Clinical Professor of Pediatrics and Health Care Policy at the Harvard Medical School, Professor of Health Policy and Management at the Harvard School of Public Health, and as a member of 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 U.S. Preventive Services Task Force, the first “Independent Member” of the Board of Trustees of the American Hospital Association, and chair of the National Advisory Council of the Agency for Healthcare Research and Quality. An elected member of the Institute of Medicine (IOM), Dr. Berwick served two terms on the IOM’s governing Council and was a member of the IOM’s Global Health Board. He served on President Clinton’s Advisory Commission on Consumer Protection and Quality in the Healthcare Industry. He is a recipient of numerous awards, including the 1999 Joint Commission’s Ernest Amory Codman Award, the 2002 American Hospital Association’s Award of Honor, the 2006 John M. Eisenberg and Quality Award for Individual Achievement from the National Quality Forum and the Joint Commission on Accreditation of Healthcare Organizations, the 2007 William B. Graham Prize for Health Services Research, the 2007 Heinz Award for Public Policy from the Heinz Family Foundation, the 2012 Gustav O. Lienhard Award from the IOM, and the 2013 Nathan Davis Award from the American Medical Association. In 2005, he was appointed “Honorary Knight Commander of the British Empire” by the Queen of England, the highest honor awarded by the UK to non-British subjects, 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 four books. He also serves now as Lecturer in the Department of Health Care Policy at Harvard Medical School, and as a Senior Fellow at the Center for American Progress. 25th Annual National Forum on Quality Improvement in Health Care Special Interest workshop Tracks keynotes A1: Removing Waste From Health Care: Lessons from Choosing Wisely and the Right Care Alliance Tuesday, December 10 • 9:30 AM - 10:45 AM Daniel Wolfson, Executive Vice President & COO, ABIM Foundation Shannon Brownlee, Senior Fellow, Lown Institute Vikas Saini, President and CEO, Lown Institute Seventy-five workshops are offered during the General Conference (December 10 and 11). The sessions are organized into content areas—or “tracks”—that follow IHI’s five focus areas. Participants can enroll in sessions individually or follow one of these strategic tracks: Tracks B1: Global Lessons in Improvement from Around the World Tuesday, December 10 • 11:15 AM - 12:30 PM Nigel Crisp, Former Permanent Secretary in Health, United Kingdom and Former Chief Executive, National Health Service England (Moderating a panel including): Göran Henriks, Chief Executive of Learning and Innovation, The County Council of Jönköping, Sweden Wim Schellekens, MD, Strategic Advisor, The Hague Area, The Netherlands Jason Leitch, Clinical Director, Quality Unit, Scottish Government Health Department, Scotland Haidee Davis, General Manager, Ko Awatea, Counties Manukau District Health Board, New Zealand Sodzi Sodzi-Tettey, MD, Executive Director, Department of Health, National Catholic Secretariat, Ghana Mike Richmond, Chief of Clinical Affairs, Hamad Medical Corporation, Qatar • Quality, Cost, and Value • Improvement Capability • Triple Aim for Populations • Person- and Family-Centered Care • Patient Safety Session Levels at a Glance The General Conference offers workshops for various levels of learning. Sessions are sorted by experience level throughout this guide. C1: Fully Transparent Medical Records: Prospects and Problems Tuesday, December 10 • 1:30 PM - 2:45 PM Tom Delbanco, MD, Professor of General Medicine and Primary Care, Harvard Medical School and Beth Israel Deaconess Medical Center and Co-Director, OpenNotes F Fundamentals Program This series of sessions offers helpful ideas and tools for newcomers to the world of quality improvement. Jan Walker, RN, Principal Associate in Medicine, Harvard Medical School and Beth Israel Deaconess Medical Center and Co-Director, OpenNotes M Masters Program D1: The Role of Leaders in Building a Culture of Continuous Improvement Wednesday, December 11 • 9:30 AM - 10:45 AM For the advanced learner, this series of sessions provides cutting-edge improvement thinking from health care and other industries. Shahab Saeed, Vice President & COO, Questar Energy Services S Student Program E1: Environmental Sustainability and the IHI Triple Aim Wednesday, December 11 • 11:15 AM - 12:30 PM Donald Berwick, MD, MPP, President Emeritus and Senior Fellow, IHI (Moderating a panel including): Blair Sadler, Senior Fellow, IHI Gary Cohen, Executive Director, Health Care Without Harm Selected across a wide spectrum of topics and disciplines, these sessions will accelerate the capacity for improvement of health professions students who are new to quality improvement or new to the National Forum. P Patient Presenters The sessions designated with a “P” will have a patient presenting as faculty. Robin Guenther, CEO, Perkins+Will Consulting Practice Jeffrey Thompson, MD, CEO, Gundersen Health System Welcome! Tweet your Forum thoughts using #IHI25Forum 7 PRE-CONFERENCE Sunday DECEMBER 8 (Plan, Do, Study, Act) by integrating them into their project planning and process design • Initiate a plan to build an integrated quality improvement strategy Scoville, R., PhD, Improvement Advisor and Consultant, IHI; Zak, H., President and COO, ThedaCare Center for Healthcare Value; Norouzzadeh, S., Industrial Engineer, North Shore – LIJ L2: Building Capacity and Capability: The Really Big Challenge Grand Ballroom, Salon 7 Crystal Ballroom, Salon G Many organizations claim that their efforts are well positioned to achieve the desired results. Many organizations, however, only give lip service to the role and position of QI within the organization. Are you REALLY serious about building capacity for QI? This session will define the key components of a capacity-building strategy, identify the milestones in the capacity-building journey, and describe how to assess your organization’s capacity for sustained change. If you are new to the National Forum, we suggest that you attend one of the National Forum orientation sessions to help you navigate through the program and devise a personal learning plan. Participation in the National Forum orientation is free, and registration is not required. After this session, participants will be able to: • Define the key components of a capacity-building strategy • Identify key milestones in the capacity-building journey • Assess their organization’s capacity for sustained change National Forum Orientation 11:00 AM – 12:00 PM Learning Labs 1:00 PM – 4:30 PM Learning Labs offer specific “how-to” improvement information. These half-day sessions allow full engagement, discussion, and ample time for Q&A. L1: Building an Integrated Approach to Lean, Six Sigma, and the Model for Improvement Crystal Ballroom, Salon D What approach to quality improvement does your organization follow? Lean, Six Sigma, The Model for Improvement (M4I)? All approaches have value, but many organizations lack what Edwards Deming called “constancy of purpose” and end up confused about which methods are best and how to apply them in specific contexts. This workshop will help participants clarify the similarities and differences between these three approaches, provide a framework for organizing their overall quality improvement strategy, and offer hands-on experience with key Lean and M4I tools. After this session, participants will be able to: • Describe the similarities and differences between Lean, Six Sigma, and M4I approaches to quality improvement • Select and apply important Lean and M4I tools, such as Value Stream Mapping, A3 design, Quality as a Business Strategy, and PDSA 8 L4: How Much Is Enough? Sampling for Improvement M Crystal Ballroom, Salon K-M Sampling methods for improvement differ from those associated with research and judgment measures, and confusion on this point can lead to sampling waste, inefficiencies, and delayed learning. This session will present practical criteria to determine appropriate sample sizes for quality improvement work, as well as the resource burden of sampling. Specific topics include guidelines for scaling PDSA cycles and determining appropriate sample sizes for run charts and Shewhart control charts. After this session, participants will be able to: • Describe the principles for sampling for improvement • Estimate the resource burden of sampling • Select appropriate scale for PDSA cycles Murray, S., Improvement Advisor, CT Concepts; Provost, L., Statistician, Associates in Process Improvement; Perla, R., Director, Analytics, University of Massachusetts Memorial Medical Center Luther, K., RN, Vice President, IHI; Kotagal, U., Senior Vice President, Quality and Transformation, and Director, Health Policy and Clinical Effectiveness, Cincinnati Children’s Hospital Medical Center; Schilling, L., RN, National Vice President, Healthcare Performance Improvement, Kaiser Permanente Improvement Capability L3: Health Care 3.0— The Nuka System of Care Increasingly, state, regional, or national indicators are used for accountability assessments of the quality and safety of health care providers, usually aggregated by quarter or year and most often lagged by a year or more. These indicators are not typically used for improvement. This session will not only clarify the different approaches to measurement but also show how to fully integrate aggregated outcome indicators into an organization’s improvement journey. Rather than ignoring or challenging aggregated national indicators or rationalizing their position in a rank ordering of providers, leaders should be using these data to develop a more integrated approach to measurement. Both statistical and graphical data integration will be demonstrated in this session. Participants will also be challenged to assess their own measurement systems and articulate their reasons for measuring. Sawgrass Quality, Cost, and Value Tierney, S., MD, Chief Medical Informatics Officer and Medical Director, Clinic Quality Improvement, Southcentral Foundation; Eby, D., MD, Vice President of Medical Services, Southcentral Foundation Southcentral Foundation, awarded the Malcolm Baldrige National Quality Award in 2011, has been a National Center for Quality Assurance (NCQA) patient-centered medical home (PCMH), Level 3 (highest level), since 2010. The standards of the PCMH are just the starting point for transforming a health care system. This session will review approaches that go beyond the PCMH starting point to create and sustain relationships, including approaches for the recruitment, retention, and training of workforce; and for information management from data systems to support the new approach. After this session, participants will be able to: • Review an entire health care system’s transformational journey from physician-centered to patient-centered to customer-owned • Detail the ways in which a health care system that has been redesigned and rebuilt from the perspective and ownership of the community results in better outcomes than a faster and leaner version of the current medical system • Describe approaches for moving beyond PCMH to Health Care 3.0, including workforce and information management from data systems and sustaining relationships L5: Are National Indicators Useful for Improvement Work? Grand Ballroom, Salon 8 After this session, participants will be able to: • Explain the differences and similarities between measurement for improvement, judgement, and research • Describe ways to analyze data for improvement • Assess their personal approach and their organization’s approach to measurement Lloyd, R., PhD, Executive Director, Performance Improvement, IHI; Henriks, G., Chief Executive of Learning and Innovation, County Council of Jönköping 25th Annual National Forum on Quality Improvement in Health Care L6: Design Your Way to Better Service Crystal Ballroom, Salon J Design methods bring new insights and understanding about how you are actually providing services… and show you that all is not what you think. As they learn, share, laugh, and generally have fun, participants in this highly interactive workshop will gain hands-on experience in using effective service design approaches to transform the services they provide. After this session, participants will be able to: • Articulate what they don’t know about the services they provide • Experiment with new approaches to providing better service in their own organization Maher, L., PhD, Director for Innovation, Ko Awatea; McCarthy, C., Director, Innovation Learning Network, Kaiser Permanente L7: Designing for Flow: Who’s Caring for Mary? New York/New Orleans Lack of flow within a hospital often stems from poorly designed systems that lack sufficient resources. Such systems are also associated with increased harm to patients. Designing for flow has safety benefits not only for patients but also for organizations. This Learning Lab will describe the links between flow and harm, providing methods for identifying flow issues and detailing concepts that can be used to improve flow and consequent safety. After this session, participants will be able to: • Identify system defects and opportunities to improve flow within their organization • Develop strategies for understanding and preempting flow issues • Implement recognized strategies for system redesign Boulton, J., MB ChB, Consultant Rheumatologist and Clinical Lead for Quality Improvement, Sheffield Teaching Hospital; Mackenzie, S., Medical Director for Quality Improvement and Safety, NHS Lothian L8: Disaster Management in Health Care: Principles and Practices of Emergency Preparedness Grand Ballroom, Salon 9-10 Emergency preparedness involves more than just having a plan. To be truly prepared, a comprehensive approach is required that ensures the safety of patients, employees, and the surrounding community while maintaining continuity of operations. This session will detail lessons learned by the North Shore-LIJ Health System during various types of incidents (terrorism, infectious disease outbreaks, and weather-related emergencies) and how these lessons were integrated into a comprehensive emergency management program After this session, participants will be able to: • Prepare a comprehensive emergency management program • Describe the steps necessary to ensure the safety of patients, employees, and the community during an incident • Discuss vital components of a business continuity plan Solazzo, M., Executive Vice President and Chief Operating Officer, North Shore-LIJ; Jarrett, M., MD, Senior Vice President/Associate CMO and Chief Quality Officer, North Shore-LIJ; Romagnoli, J., Vice President, Protective Services, North Shore-LIJ; Mahoney, M., NP, Director, Emergency Planning and Preparedness, North Shore-LIJ L9: Enhance Safety and Reduce Cost by Improving Flow Crystal Ballroom, Salon N The need to develop new ways to deliver health care has become more apparent with funding constraints and the failure of safety systems. This session will demonstrate how to deliver safe and effective care in a cost-effective way. Participants will learn why the application of operations management theory is the key to an affordable and safe health service. The principles of the management of variability and queuing theory will be illustrated by case studies and participatory work. After this session, participants will be able to: • Explain the relationship between flow, safety, and cost • Implement the principles of managing operations • Describe the key challenges in redesigning the flow of patients to improve safety Litvak, E., PhD, President and CEO, Institute for Healthcare Optimization; Lachman, P., MD, Associate Medical Director and Consultant in Service Redesign and Transformation, Great Ormond Street Hospital for Children NHS Trust; Leitch, J., Clinical Director, Quality Unit, Scottish Government Health Department L10: How to Publish Your Improvement Work M Vinoy This session will advance participants’ writing skills with the goal of reporting on their health care improvement efforts for scholarly publication. Participants will bring their own improvement work—at any stage of development—for use in hands-on writing exercises. Faculty will employ a new draft version of the SQUIRE publication guidelines for reporting health care improvements to help participants prepare their work for publication. This session will also provide timely updates on health care improvement science and obtaining appropriate ethics reviews. After this session, participants will be able to: • Use writing techniques that are applicable to scholarly publication of their health care improvement efforts • Apply the evolving SQUIRE publication guidelines to achieve greater success in publication Stevens, D., MD, Editor Emeritus, BMJ Quality & Safety, The Dartmouth Institute for Health Policy and Clinical Practice; Batalden, P., MD, Professor, The Dartmouth Institute for Health Policy and Clinical Practice; Davidoff, F., MD, Executive Editor, IHI; Davies, L., MD, Assistant Professor of Surgery, Dartmouth Medical School; Ogrinc, G., MD, Associate Professor, Community and Family Medicine, White River Junction VA Medical Center L11: How to Transform Your Practice into a Medical Home F Crystal Ballroom, Salon G The patient-centered medical home (PCMH) has rapidly gained momentum as a strategy for delivering high-quality, affordable health care. By emphasizing a comprehensive, collaborative working relationship between clinicians, patients, and families, the model creates a team-based, data-driven infrastructure in which care is coordinated, community resources are integrated, and patients are supported as decision-makers. This Learning Lab will focus on building internal capacity to lead change efforts to help transform your practice into a medical home. After this session, participants will be able to: • Identify the elements and benefits of the PCMH • Determine the barriers and challenges that must be overcome to implement this model in their own practice • Develop a plan for designating and training a local leader to transform their practice into a medical home Anand, S., MD, Physician Champion, National Initiative for Children’s Healthcare Quality (NICHQ); Fitzgerald, E., DrPH, Associate Director, NICHQ; Homer, C., MD, CEO, NICHQ L12: Knowledge Management Strategies for Large-Scale Improvement Harbor Beach Implementing effective learning strategies for large-scale improvement programs is a challenge. This Learning Lab will provide theory, practical examples, and structured guidance on tested strategies for successful large-scale learning. Faculty will discuss strategies for face-to-face learning as well as novel ideas about how to move information and best practices around and between dispersed participants in learning networks. Lessons from the US, Scotland, and Africa will be used to describe the models. After this session, participants will be able to: • Describe the framework that IHI uses for knowledge management in large-scale projects • Draw lessons and strategies from the IHI experience in large-scale learning events and learning platforms for dispersed participants • Employ tools and methods for building learning systems and knowledge management platforms Webster, P., Improvement Advisor, IHI; Lewis, N., Director, IHI; DeBartolo, K., National Field Manager, IHI How is your Learning Lab? Tweet your thoughts using #IHI25Forum 9 PRE-CONFERENCE L15: Person-Centered Health IT: Making IT Happen Grand Cayman/Puerto Rico Sunday DECEMBER 8 Learning Labs 1:00 PM-4:30 PM L13: Lean Health Care Principles: Interactive Diagnosis and Problem-Solving F Grand Ballroom, Salon 1-2 This interactive session will teach the principles of Lean health care. Participants will start by viewing a Flexsim Simulation video of a dysfunctional emergency department. Teams of participants will brainstorm and describe the various levels of dysfunction. Teams will then brainstorm solutions, and present them to the whole group. The best-practice solutions, with implications for a variety of health care settings, will be discussed at the end of the session. After this session, participants will be able to: • Describe applications of Lean principles and tools • Evaluate a clinical scenario • Apply Lean and flow principles Crane, J., MD, Emergency Medicine Faculty, IHI; Jensen, K., MD, Chief Medical Officer, BestPractices, Inc. L14: Mesosystems and Pathways: Idealized Design Crystal Ballroom, Salon E-F Organizations are becoming more and more aware of the need to improve, coordinate, and design “mesosystems” of care—that is, two or more microsystems and patient pathways. In this session, participants will explore the essential skills of assessment, creating community, leveraging relationships across the organization, and developing leadership. After this session, participants will be able to: • Identify and assess one mesosystem of care • Practice designing and using the central data room to drive innovation and the monitoring of improvement • Design an individual action plan to assess, redesign, and monitor a mesosystem in their organization Godfrey, M., RN, Co-Director, The Microsystem Academy, and Instructor, The Dartmouth Institute for Health Policy and Clinical Practice; Downes, T., Consultant Geriatrician, Sheffield Teaching Hospitals; McKinley, K., RN, Vice President, Special Projects, Division of Quality and Safety, Geisinger Health System 10 Many high-performing health care organizations that truly focus on person-centered care are increasingly exploiting health information technology (IT) to support their efforts. Are you wondering how health IT might improve the services you offer to patients? Participants in this session will consider what is generalizable from the early adopters of health IT to support patient-centered care and work together to think through how their own organizations might adapt lessons from leaders in the field. After this session, participants will be able to: • Describe the role health IT plays in patient-centered care • Appreciate the international experience of patient-centered health IT • Identify the key elements of patient-centered health IT and assess their organization’s progress against these elements Robson, B., MB ChB, Executive Clinical Director, Healthcare Improvement Scotland; Adams, L., President and CEO, Rhode Island Quality Institute; Hunt, J., PharmD, Independent Consultant L16: Rapid-Cycle Evaluation for Improvement Leaders M Crystal Ballroom, Salon A-C It is crucial that health system leaders and researchers who are testing improvement interventions are able to evaluate and share what they have learned. Improvement interventions are often complex and can change as the work unfolds, making evaluation approaches complex. This session will use a mix of presentations and participatory case studies to explore a rapid-cycle evaluation approach to learning from improvement interventions and to share with others what’s been discovered. Participants will be encouraged to share ideas about their own work. After this session, participants will be able to: • Describe two methods for evaluating improvement work • Test the effectiveness of a quality improvement intervention, both with and without the use of comparison groups Parry, G., PhD, Senior Scientist, IHI; Reid, A., Research Associate, IHI; Cohen, S., MSW, Research Associate, IHI Triple Aim for Populations L17: Building the “ImproveCareNow” Learning Health System P West Indies “ImproveCareNow” evolved from a small quality improvement (QI) collaborative to a national collaborative chronic care network and learning health care system that engages patients, families, clinicians, and researchers. In this session, we will discuss how point-of-care data, patient-reported outcomes, and innovative technology create a robust registry not only for QI (including patient activation, automated pre-visit planning, and population management) but also for research (including simulated clinical trials) and innovation. Participants will have an opportunity to learn about the dramatic improvement in outcomes achieved. After this session, participants will be able to: • Describe how to develop a network of health care organizations, patients, families, and clinicians focused on improving patient outcomes • Leverage data for improvement, including the concepts of a patient registry, “data-in-once”, and the repurposing of data • Identify ways to increase team efficiency in a QI and research collaborative, including automated reporting and the use of a federated institutional review board Crandall, W., MD, Professor of Clinical Pediatrics and Associate Medical Director, Nationwide Children’s Hospital; Margolis, P., Director of Research, James M. Anderson Center for Health Systems Excellence, Cincinnati Children’s Hospital Medical Center; Colletti, R., Network Director, University of Vermont College of Medicine; Moon, T., Parent Quality Improvement Representative, Nationwide Children’s Hospital L18: Changing Population Health: Physician, Heal Thyself F Miami Unhealthy lifestyles contribute to increases in health care costs at a time when resources are severely strained. With obesity reaching epidemic proportions, the challenge lies in responding quickly and effectively. Bellin Health and NHS Wales (UK) are tackling the problem by addressing employee health with the aim of impacting the wider population. Health care staff are a significant element of the population, and this challenge presents them with an important leadership opportunity. After this session, participants will be able to: • Explain the link between employee health and population health • Describe two approaches that have been undertaken to improve health behaviors and reduce disease risks • Explore how a targeted communications campaign can contribute to successful behavior change in participants Knox, P., Executive Vice President, Bellin Health; Kerwin, G., President and CEO, Bellin Health; Cooper, A., Head of Communications and Marketing, Public Health Wales; Willson, A., PhD, Director, 1000 Lives Plus, Public Health Wales 25th Annual National Forum on Quality Improvement in Health Care L19: Improving Transitions from the Hospital to Community Settings L21: MiPCT: Michigan’s “Model T” for Transforming Care Grand Ballroom, Salon 3 Key Biscayne The transition from the hospital to post-acute care settings has emerged as an important priority in reducing avoidable rehospitalizations. Hospitals have an important role in designing and reliably implementing effective discharge processes to improve the transition from hospital to home or to the next care setting. In this session, four research and improvement initiatives that aim to improve discharge processes in hospitals and reduce rehospitalizations will be highlighted: IHI’s STAAR (STate Action on Avoidable Rehospitalizations) Initiative, the Society of Hospital Medicine’s Project BOOST (Better Outcomes for Older adults through Safe Transitions), the Agency for Healthcare Research and Quality’s Project RED (Re-Engineered Discharge), and the Hospital to Home (H2H) initiative co-sponsored by the American College of Cardiology and IHI. This session will focus on how three diverse practice organizations used a Centers for Medicare and Medicaid Services (CMS) demonstration project, the Michigan Primary Care Transformation (MiPCT), to advance care management within their organizations. After this session, participants will be able to: • Identify promising approaches for hospital clinicians and staff to improve the transition from the hospital to post-acute care settings • Compare and contrast the strategies used in the STAAR, Project BOOST, Project RED, and H2H initiatives • Identify the common elements of these four initiatives Rutherford, P., RN, Vice President, IHI; Jack, B., MD, Professor and Chair, Department of Family Medicine, Boston University School of Medicine; Nielsen, G., Fellow and Faculty, IHI; Horwitz, L, MD, Assistant Professor, Yale University L20: Primary Care Transformation in Academic Medical Centers St. Thomas This session will highlight the experience of 18 primary care academic practices in their move to full team-based care, empanelment, and the care of populations—the foundations of robust patient-centered medical homes. We will discuss practical solutions to common problems in academic settings, and patient/family and residency training representatives will share their experience as part of the transformation work. After this session, participants will be able to: • Identify successful strategies for setting up primary care transformation in an academic setting • Describe practical strategies in the move to team-based care and empanelment in academic primary care practices • Describe how to include patient input in the work of primary care transformation Sevin, C., RN, Director, IHI; Bitton, A., MD, Associate Physician, Brigham and Women’s Hospital; Sugarman, J., MD, CEO, Qualis Health; Pabo, E., MD, Manager of Practice Improvement, Harvard Medical School; Steinfield, R., Improvement Advisor, IHI After this session, participants will be able to: • Identify ways to leverage the electronic medical record to facilitate care management and clinician communication across their organization • Apply effective strategies to engage their team • Optimize care management resources in a multi-payer environment Seguin, C., Director, Henry Ford Health System; Sayers, D., DO, Regional Medical Director, Northern Region, Henry Ford Health System; Nicolaou, L., Care Manager, West Front Primary Care; Bennett, K., Senior Quality Specialist, Sparrow Medical Group L22: Strategies for Managing Populations: A Platform and Portfolio Approach Marco Island The Patient Protection and Affordable Care Act (ACA) has started a transition in the US health care system from a focus on health care production to population management. This is leading health care systems to think about what they need in order to be able to manage populations. During this session, we will discuss an overall approach to population management based on research and development work at IHI and knowledge gained from work in the Triple Aim for the last eight years. After this session, participants will be able to: • Describe the population management issues that hospitals face • Apply the IHI framework to help them manage the population they serve Whittington, J., MD, Lead Faculty, Triple Aim Initiative, IHI; Kabcenell, A., RN, Vice President, IHI; Ramsay, R., Director of Community Care, CareOregon Person- and Family-Centered Care L23: ALL IN: Exceptional Patient and Family Experiences M P Grand Ballroom, Salon 11 We know that the relationships and experiences of patients and families in health care are key components of achieving the best overall care outcomes in all health care settings. But what steps should be taken to enhance these relationships and experiences, and whose job is it to do so? This session will describe the critical aspects of strategic alignment; team engagement and skills for physicians, nurses, team members, and patient advisors; individual and team accountabilities; and infrastructure that creates the best outcomes and the best work environment. After this session, participants will be able to: • Describe the relationship between patient and family experience and health care outcomes • Identify and use the critical aspects of strategic alignment • Develop action plans to share with colleagues Hayward, M., Lead, Patient and Family Engagement, IHI; Balik, B., RN, Senior Faculty, IHI, Consultant, Common Fire Healthcare Consulting; White, K., President, Aerate Consulting L24: Coaching the Conversation about End-of-Life Care Key Largo Are you eager to bring The Conversation Project to your organization? During this session, members of The Conversation Project team will lead participants through a two-part framework for leading Conversation Groups, offering them the opportunity to practice with peers and practice responding to difficult scenarios. In this interactive session, as participants share ideas on how they think about their own end-of-life care, they will also reflect on and relate their personal and professional experiences. After this session, participants will be able to: • Describe The Conversation Project and the role of both health care providers and individuals in discussing personal wishes for end-of-life care • Develop an action plan that includes both professional and personal conversations • Identify the barriers to having the end-of-life conversation and the strategies and tools available to promote action Warshaw, H., Executive Director, The Conversation Project; McCannon, J., MD, Faculty, IHI; McCutcheon Adams, K., LICSW, Director, IHI L25: Perinatal Quality Model Applications F Crystal Ballroom, Salon P-Q Beginning in 1995 with The Breakthrough Series, organizations have partnered with IHI to improve outcomes by improving structure and process. Continuous learning on translational leadership and adult learning has driven new levels of engagement with multidisciplinary stakeholders— including patients and families. As the oldest such learning community, IHI’s Perinatal Improvement Community continues to push deeper into new knowledge. In this session perinatal faculty will share current knowledge on four key areas—patient experience, health outcomes, cost, and workforce. After this session, participants will be able to: • Identify opportunities to collaborate with and engage health systems in their region or state to improve outcomes for mothers and babies • Apply knowledge that supports learning and translational leadership Cherouny, P., MD, Emeritus Professor, Obstetrics, Gynecology, and Reproductive, University of Vermont; Johnson, C., RN, Director of Obstetrics, Woman’s Hospital; Gullo, S., RN, Director, IHI; Crowe, G., RN, Principal, Hamilton Consulting, LLC How is your Learning Lab? Tweet your thoughts using #IHI25Forum 11 PRE-CONFERENCE Sunday DECEMBER 8 Learning Labs 1:00 PM-4:30 PM After this session, participants will be able to: • Discuss the unique safety challenges in ambulatory settings • Describe tools for developing teamwork in ambulatory practices • Identify two methods for capturing and analyzing harm and error in an ambulatory setting Haraden, C., PhD, Vice President, IHI; Gandhi, T., MD, President, National Patient Safety Foundation (NPSF) L28: Improving the Flow of Resident and Hospitalist Work Aruba/Bahamas L26: The Disparities Leadership Program: Implementing Strategies to Address Disparities Anaheim The Disparities Leadership Program (DLP) is a year-long executive education program designed to assist health care leaders with developing a strategic plan or project to eliminate racial and ethnic disparities in their health care organizations. In this session, we will discuss the barriers and challenges to advancing and implementing strategies to address disparities, the role of the DLP framework in translating research findings into implementation, and examples of success in the DLP approach to addressing health disparities. After this session, participants will be able to: • Recognize the root causes of disparities in the quality of care • Describe the approaches taken by some health care organizations to identify and address racial and ethnic disparities • Discuss the challenges, successes, and next steps in addressing health care disparities Betancourt, J., MD, Director, The Disparities Solutions Center, Massachusetts General Hospital (MGH); Tan-McGrory, A., Deputy Director, MGH; McCracker, K., Director of Operations, Manchester Community Health Center Patient Safety L27: Creating a Culture of Safety in an Ambulatory Care Setting Grand Ballroom, Salon 4-6 Improving safety and culture has long been the work of hospitals, but most people receive the majority of care over their lifetime in ambulatory settings, where the work is different and so are the safety challenges. Methods of improving safety and culture in acute care settings are not always appropriate for ambulatory practices. The methods used to capture, analyze, and reduce harm and error must match the work and be usable by the ambulatory team. In this session, participants will learn how creating an ambulatory care environment where risks are anticipated, teamwork is standard, and patient partnerships are maximized allows a culture of safety to flourish. 12 Hospital teaching rounds are a time-honored tradition and a fundamental aspect of residency training. In most institutions, the basic format of rounds has not changed for decades. In this session, we describe how Virginia Mason Medical Center improved the work flow of residents and hospitalists by applying the principles of the Virginia Mason Production System. Morning rounds were redesigned to allow residents to complete high-quality and timely patient care, one patient at a time. After this session, participants will be able to: • Recognize the impact of batch rounding on the clinical operations and educational experiences of hospitalists and residents • Demonstrate the differences between batch rounding and one-piece flow rounding • Plan a cycle of improvement to reduce batching in their hospital rounds Calderon, A., MD, PhD, Program Director, Internal Medicine Residency Program, Virginia Mason Medical Center; Hanson, D., Hospital Medicine Director of Quality and Safety, Virginia Mason Medical Center L29: Integrating Patient Safety into Your System’s DNA F Grand Ballroom, Salon 12-14 Since the beginning of the new millennium, research on topics related to patient safety has led to numerous solutions that could make care processes more reliable and improve patient outcomes. Implementation, however, has lagged behind, and global progress has been disappointing. In this session, participants will study and discuss the components of an institutional improvement program, with an emphasis on system-wide implementation and sustainability. After this session, participants will be able to: • Describe the key components of an institutional patienty safety improvement program • Articulate how some organizations have implemented these components • Discuss how to develop a culture of safety and continuous learning Federico, F., RPh, Executive Director, Strategic Partners, IHI; Peden, C., MB ChB, MD, Associate Medical Director for Quality Improvement, Consultant in Anesthesia and Intensive Care, Royal United Hospital, Bath; Staines, A., PhD, Associate Professor, University of Lyon L30: Intelligent Measurement for Intelligent Boards Chicago/Denver Measures of patient safety, including adverse incident reporting and global trigger tool reports, are often supplemented with other process and outcome measures to develop dashboards. In this session, we will review the available tools for measuring harm, the essential elements of a safety dashboard, the ways in which dashboards measure harm, the pitfalls of current approaches, and new composite measures of harm. Innovations in safety measurement will also be presented and discussed. After this session, participants will be able to: • Describe both advantages and limitations of the current approaches to measurement taken by CEOs and boards • Discuss the essential elements of a safety surveillance system that can optimize oversight by senior leaders and boards • Identify the skills and support required by boards to actively measure and monitor safety Dalton, D., Chief Executive, Salford Royal Hospital Foundation NHS Trust; Power, M., Director, Salford Royal Hospital Foundation NHS Trust Sunday SPECIAL EVENT International Attendee Meeting 5:00 PM – 7:00 PM Crystal Ballroom, Salon D All National Forum attendees are invited to take advantage of this informal opportunity to network with international peers who are working on health systems improvements around the world and hear about the strategic vision and current execution of IHI’s global work. 25th Annual National Forum on Quality Improvement in Health Care PRE-CONFERENCE Monday DECEMBER 9 National Forum Orientation 7:00 AM – 8:00 AM FE2: Universal Orlando®: Safety and Reliability G Gaylord Palms: Sun Ballroom 5-6 FE6: Gaylord Palms: Joy in Work and Customer Satisfaction G Gaylord Palms: Sanibel Sword fights…staged gun shots…boat explosions…What do these have in common with patient safety and reliability in health care? Learn how the Universal stunt team ensures safety of staff and visitors during high-risk stunts and addresses reliability when there are handoffs and staffing changes as well as what they do when unexpected events occur. Stunt actors will demonstrate how they routinely focus on the Universal Orlando® culture of “safety first.” Customer satisfaction starts with staff satisfaction at this large hotel and convention center. In studying how the Gaylord Palms handles staffing assignments, manages unprofessional behavior, and keeps employee attrition rates lower than the industry standard, participants will learn best practices for incorporating “joy in work.” Lloyd, R., PhD, Executive Director, Performance Improvement, IHI; Griffin, F., Faculty, IHI FE7: Darden Restaurant Group G Gaylord Palms: Captiva FE3: Central Florida Zoo: Patient Care and Operations G Gaylord Palms: Tallahassee 1-2 If you are new to the National Forum, we suggest that you attend one of the National Forum Orientation sessions to help you navigate through the program and devise a personal learning plan. Participation in a National Forum orientation is free. Behind the scenes of the Central Florida Zoo, we will discover examples of key efficient safety processes as they care for over 400 very special “patients.” Participants will learn details of the zoo’s operations, safety protocols (for both humans and wildlife), and crisis management planning. Zoo staff will also share their methods of caring for, feeding, and managing many types of animals at once. Forum Excursions Duncan, K., RN, Faculty, IHI; Bell-Polson, D., Director of Maternal Child Health, Lawrence General Hospital Crystal Ballroom, Salon G 8:30 AM – 5:00 PM With the exception of the Marriott Excursion (FE1), all Excursions start at the Gaylord Palms Resort and Convention Center. Participants will then be transported to their selected destination for a three-hour tour and presentation led by destination staff and IHI faculty. Afterward, participants will explore the lessons learned and their applicability to health care during an afternoon “deep dive” led by IHI faculty. FE1: Marriott World Center: Manage Large-Scale Operations Marriott World Center: Key West Participants will learn how the Marriott manages the processes for ensuring efficient flow/throughput of large volumes of visitors, yet still manages to offer superb customer service in the front office; adhere to tight schedules in the banquet kitchen; run a golf club; tend to every detail of event and convention services; and manage daily housekeeping operations. Gullo, S., RN, Director, IHI; Loehrer, S., MD, Director, IHI FE4: LEGOLAND Florida: Managing Complex Adaptive Systems G Gaylord Palms: Sun Ballroom 1-2 See for yourself how this popular destination, new to Orlando, manages complex processes to engage, teach, and entertain thousands of children and adults every day. Meet with managers responsible for sales, visitor experience, and lego model building. Participants will also have an opportunity to meet with corporate leaders to learn about and discuss strategies for managing the complex, adaptive systems that exist within LEGOLAND. Gunther-Murphy, C., Director, IHI; Dickson, E., MD, President and CEO, UMass Memorial Health Care Darden is the world’s largest full-service restaurant company with annual sales of $8 billion, and their family of restaurants includes Red Lobster, Olive Garden, Longhorn Steakhouse, Bahama Breeze, Seasons 52, The Capital Grille, Eddie V’s and Yard House—2,100 North American locations in all. Recognized for its commitment to diversity and sustainability, Darden also has been named to the Fortune “100 Best Companies to Work For” list for the past three years. In this interactive Excursion, Darden executives, including President Eugene Lee, will discuss the company’s multi-brand strategy, talent and culture management, marketing and branding, use of social media, food procurement and safety, and community and government affairs. Swensen, S., MD, Medical Director, Leadership and Organizational Development, Mayo Clinic; Berry, L., PhD, Distinguished Professor of Marketing, Texas A&M University On Monday morning, shuttle buses will be available to the Gaylord Palms from all National Forum hotels. Bones, K., MSW, Project Director, IHI; Levy, P., Author FE5: EA SPORTS – Tiburon: Innovation and Creativity G Gaylord Palms: Sun Ballroom 3-4 Join the leaders in the video game industry as they describe how they foster an environment of continuous innovation and creativity. Members of IHI’s Innovation Team will guide participants as they hear about EA SPORTS – Tiburon’s new product design processes, learn about their methods for keeping pace with customer preferences, and explore their approach of team engagement. Johnson, M., Senior Research Associate, IHI; Moses, J., MD, Director of Safety and Quality, Department of Pediatrics, Boston Medical Center How is your Forum Excursion? Tweet your thoughts using #IHI25Forum 13 PRE-CONFERENCE Monday DECEMBER 9 Virtual Site Visits Morning Visits: 8:30 AM – 12:00 PM Afternoon Visits: 1:00 PM – 4:30 PM Virtual Site Visits allow attendees to gain an in-depth understanding of how improvement work is accomplished within best-practice organizations via virtual tours and video interviews with front-line staff and leadership. Attendees will choose two organizations to visit virtually. Morning Virtual Site Visits VSV1: Jönköping and Qulturum, Sweden Anaheim Jönköping County Council is a health care system with the responsibility to provide health care, medical treatment, and dental services for the residents within Jönköping County, Sweden. This session will focus on the strategic goals identified by the by Jönköping County Council as key areas to improve health care and increase the value of the services for the patients and population. The drive for improvement in these areas is supported by Qulturum. Qulturum is a center for learning and transformation of care and its main focus is on facilitating improvement in the fields of patient involvement, prevention, cooperation, clinical improvement, and safety, coaching teams, and designing health care services. After this session, participants will be able to: • Describe the key areas to improve health and increase the value of services as identified by Qulturum in Sweden • Identify best practices that can be brought back to their organizations Henriks, G., Chief Executive of Learning and Innovation, The County Council of Jönköping; Rukat, A., Coordinator, Qulturum, Sweden VSV2: Bellin Health System Crystal Ballroom, Salon E-F The Bellin Health virtual site visit will focus on the high-performance health care model. This model consists of aligning six dimensions: Strategic clarity; production system design; measurement system design; improvement/innovation; sales/ marketing; and culture. This business model 14 aligns and deploys strategy to achieve results. In the high-performance model, the shift is away from activity, towards an execution framework that maximizes organizational energy around high-leverage priorities necessary for achieving strategic results. In this presentation, this model will be presented using a mix of video and verbal discussion. After this session, participants will be able to: • Describe the six dimensions of the high performance health care model • Identify best practices that can be brought back to their organizations • Explain the framework for managing priorities and making decisions about organizational focus Kerwin, G., President and CEO, Bellin Health; Knox, P., Executive Vice President, Bellin Health VSV3: Kaiser Permanente Crystal Ballroom, Salon P-Q If you could imagine the future of health care, what would it look like? At Kaiser Permanente, we are committed to helping shape the future of health care. This presentation will explore how our journey to transform health care began with our mission, the will of leadership, and listening to our patients. From there, we worked across the organization—from the front-line to executives—to develop ideas that improve the care we deliver. Finally, we executed on systems to drive these improvements. This session will explore the role of physician engagement and leadership in this transformation. Additionally, participants will discuss whether excellence is good enough in the current environment. Finally, this Virtual Site Visit will examine how Kaiser Permanente is leveraging learning and using our excellent performance as a platform to accelerate improvement for our 9 million members. After this session, participants will be able to: • Extract key elements from Kaiser’s journey that could be applied to their system • Identify best practices that can be brought back to their organizations • Consider when excellence is not enough and the need to shift from celebration to acceleration Chase, A., Senior Vice President, Medicare Clinical Operations and Population Care, Kaiser Permanente; Cochran, J., MD, Executive Director, The Permanente Federation VSV4: Memorial Hermann Health System Chicago/Denver Learn how Memorial Hermann rebooted its quality and safety program in 2006 to adopt the secrets of High-Reliability Organizations (HROs). Explore the HRO techniques developed in industries like air traffic control, commercial aviation, and nuclear submarines that work perfectly in the health care environment. Learn why all employees (over 20,000 at Memorial Hermann) had to learn high-reliability techniques for the safety culture to flourish. Hear from Memorial Hermann’s Board of Directors about why they made patient safety the health system’s single core value. Virtually visit our care units to see how this works on the frontline and how to develop processes for high-risk procedures like blood transfusion with better than Six Sigma reliability. Lastly, learn how this applies to our rapidly growing Accountable Care Organization, now with over 300,000 attributed lives. After this session, participants will be able to: • Describe why high-reliability is the ultimate quality and safety goal for health care organizations • State why high-reliability health care has been difficult to achieve in the past, and how they can help achieve it now • Demonstrate how a new safety culture can be developed over time with HRO techniques Shabot, M., MD, Senior Vice President and System Chief Medical Officer, Memorial Hermann; Wolterman, D., President and Chief Executive Officer, Memorial Hermann VSV5: Henry Ford Health System Miami In 2003, Henry Ford Health System (HFHS) leadership decided to pursue organizational integration to deliver the best care to HFHS patients and drive sustainable growth. CEO Nancy Schlichting set the path toward improving performance throughout the system, electing to adopt the Baldrige Criteria for Performance Excellence as a strategy for change. This Virtual Site Visit to HFHS offers an in-depth view of key changes made in the leadership system; workforce development and communication; strategic planning process; performance improvement tools and measures; the redesign of work systems and processes—including the new 200-bed Henry Ford West Bloomfield Hospital—and the creation of a culture of patient safety. These helped lead to improved patient satisfaction, employee engagement, and reduction in harm events and inpatient mortality. Since embarking on the performance excellence journey, HFHS has received five national performance awards, including the Malcolm Baldrige National Quality Award in 2011. After this session, participants will be able to: • Describe key changes made at HFHS after adopting the Baldrige Criteria for Performance Excellence • Identify best practices that can be brought back to their organizations Conway, W., MD, Executive Vice President and Chief Quality Officer, HFHS and CEO, Henry Ford Medical Group; Swanson, J., Vice President, Performance Analytics and Improvement, HFHS; Schreiber, M., MD, Senior Vice President, Clinical Transformation and Associate Chief Quality Officer, HFHS 25th Annual National Forum on Quality Improvement in Health Care Afternoon Virtual Site Visits VSV8: Gundersen Lutheran Health System VSV6: Cincinnati Children’s Hospital Medical Center Anaheim How does a health system achieve transformation? Cincinnati Children’s Hospital Medical Center (CCHMC) is deeply committed to improving health outcomes for children— beginning with senior leadership, and creating a culture of improvement throughout the organization, linking leaders to the front line. CCHMC has been on a journey of transformation, learning much in the process. This Virtual Site Visit will cover the key factors in successful health system transformation through principles such as improvement science, discovery, systems thinking and integration, caring, transparency, and resiliency. Key leaders from CCHMC will discuss how they translate these ideologies into action every day to improve health outcomes for children. After this session, participants will be able to: • Identify the critical factors in the transformational journey at their health system • Discover how their organization can leverage the dynamics of an improvement culture to deliver reliably on operations • Identify tactics to expand their reach into the community to broadly improve children’s health outcomes Kotagal, U., SVP, Quality and Transformation and Director, Health Policy & Clinical Effectiveness, CCHMC; Fisher, M., President and CEO, CCHMC; Ryckman, F., Senior Vice President, Medical Operations, CCHMC; Margolis, P., MD, PhD, Director of Research, James M. Anderson Center for Health Systems Excellence, CCHMC; VSV7: Mayo Clinic Crystal Ballroom, Salon E-F This session will allow attendees to participate in a conversation with Mayo Clinic about how legacy, heritage, values, innovation, systems, and culture drive quality improvement. Join organizational leaders in a discussion about Mayo Clinic’s approach to improving the quality of integrated, patient-centered health care. After this session, participants will be able to: • Share the mechanics of how providers work together to coordinate patient care • Describe how Mayo Clinic’s primary value “the needs of the patient come first” is the heart of employee engagement • Implement a best practice for advancing quality within their organization Dilling, J., Senior Administrator, May Clinic; Santrach, P., MD, Chair, Quality Oversight, Mayo Clinic Crystal Ballroom, Salon P-Q Gundersen Health System is committed to delivering high quality care because lives depend on it; service as though the patient were a loved one; and relentless improvement because our future depends on it. Bringing hope and health to our loved ones who face the most difficult diagnoses with no sleepless nights was the concept that pushed us to transform care. This presentation will explore Gundersen’s journey to transform care. Faculty will present through our patient Margie’s eyes as she moved from diagnosis, to treatment, and then to recovery from breast cancer. Faculty will explore examples and explanations of how we bring to the patient the best continuum of integrated care across multiple disciplines using a holistic, patientcentered approach. Finally, presenters will share how their medical and administrative leadership model and managements systems develop, drive, and sustain improvements. After this session, participants will be able to: • Describe the execution of multidisciplinary holistic care along a timeline that meets the needs of patients and families • Identify best practices that can be brought back to their organizations Barton, K., Vice President, Operations, Gundersen Health System; Bintz, M., MD, Vice President, Gundersen Health System VSV9: 2012 Baldrige Winners: North Mississippi Health System and City of Irving, Texas Chicago/Denver The Malcolm Baldrige National Quality Award recognizes US organizations in the business, health care, education, and nonprofit sectors for performance excellence. The Baldrige Award is the only formal recognition of the performance excellence of both public and private US organizations given by the President of the United States. In 2012, four organizations received this prestigious award. Join two of the four organizations—North Mississippi Health Services and the City of Irving, Texas—in a virtual tour of their respective organization. After this session, participants will be able to: • Identify lessons learned from the Baldrige journey • Glean strategies that could improve their organization’s performance Moderator: Parsons, T., Vice President, Tennessee Hospital Association Presenters: Cummings, O., PhD, Chief Strategy Officer, North Mississippi Health System; Boyd, L., Chief of Police, City of Irving, Texas Scientific Symposium on Improving the Quality and Value of Health Care 8:30 AM – 5:00 PM G Gaylord Palms Resort and Convention Center, Sun Ballroom A-B $300 The Scientific Symposium features rapid-fire presentations of peer-reviewed papers, with an afternoon storyboard session. This program will include keynote presentations by Lisa Simpson, MB BCh, MPH, President and CEO of AcademyHealth and Carolyn Clancy, MD, Assistant Deputy Undersecretary for Health, Quality, Safety, and Value, Veterans Health Association; Former Director of the Agency for Healthcare Research and Quality (AHRQ). What are you talking about during your Virtual Site Visit? Tweet it using #IHI25Forum 15 PRE-CONFERENCE Monday DECEMBER 9 Minicourses 8:30 AM – 4:00 PM Minicourses offer in-depth, hands-on learning opportunities and many take-home tools for implementing and sustaining change. Quality, Cost, and Value M1: Leadership Required for the New Era M Grand Ballroom, Salon 3 Health care leaders are under increasing scrutiny as they seek to improve the quality and cost of care for the populations they serve. For these leaders, health care reform has made the need to decrease costs—while increasing the organization’s scope of service and improving the quality of services— even more urgent. Strong leadership is essential if health care organizations are going to thrive in tomorrow’s emerging health care environment. IHI’s Leadership Model describes the five domains of action for leaders that move organizations toward improvement, innovation, and successful adaptation to the imperatives of health care reform. After this session, participants will be able to: • Discuss the challenges facing today’s health care leaders • Describe the five domains of the IHI Leadership Model, their importance to achieving organizational success, and the vital behaviors of leading health care chief executives in each of these domains • Identify methods for applying the IHI Leadership Model in their organization and fostering these vital behaviors in their leadership team Kabcenell, A., RN, Vice President, IHI; Pugh, M., President, MdP Associates, LLC; Balik, B., RN, Senior Faculty, IHI, Consultant, Common Fire Healthcare Consulting 16 Faculty will focus on ways to effectively integrate aims and outcomes (quality, cost, service, satisfaction) and enhance value to achieve savings in annual operation costs. Through the use of mock board meetings, participants will have the opportunity to wrestle with some of the most difficult problems faced by boards and to learn about best practices to overcome them. After this session, participants will be able to: • Describe a framework for understanding a board’s role in overseeing quality and safety • List three changes they could apply to improve their board’s oversight of quality and discuss three innovative best practices that their board could implement • Identify specific opportunities to decrease direct costs while improving quality Orlikoff, J., President, Orlikoff & Associates, Inc.; Benjamin, E., MD, Senior Vice President and Chief Quality Officer, Baystate Health Improvement Capability M3: A Crash Course in Social Media for Improvement F Marco Island Across the globe, leaders in health care quality improvement efforts are using Twitter and other social media to gain knowledge, share experiences, connect with patients, and influence others on a scale we could not have imagined a few years ago. The ability to tweet, for instance, is fast becoming a critical skill in the quality improvement toolkit. This session will equip participants with the basic skills needed to use Twitter and other social media as a transformative force. For anyone new to Twitter or social media, this Minicourse is an outstanding opportunity to learn skills in an accelerated way to help achieve improvement goals. After this session, participants will be able to: • Use social media confidently and effectively to support their daily health care improvement work • Identify the key components of effective and innovative social media campaigns that have changed the world, with an eye to how such campaigns can be applied to health care improvement • Appreciate the untapped energy source available through social media tools Krause, C., Krause, C., Executive Director, British Columbia Patient Safety and Quality Council (BCPSQC); Puri, A., Quality Leader, Communications and Engagement, BCPSQC; Smith, K., Digital Media and Communications Specialist, BCPSQC M2: The Role of the Board in Quality and Safety M M4: Accelerating Health Care Transformation with Lean and Innovation: The Virginia Mason Experience Sawgrass Grand Ballroom, Salon 7 This session will describe the role of governance—executive and clinical leadership—in overseeing quality and safety through an IHI framework. It’s time to dispel myths like the belief that Lean and concepts such as standard work are “anti-innovation.” Drawing on the experience of Virginia Mason Medical Center—as well as general innovation theory and its application—the presenters in this Minicourse will describe how Lean and innovation can coexist in a health care organization and intertwine to create a powerful approach that deepens and accelerates improvement. Participants will be given concrete examples of how specific innovation and creativity methods can be integrated into Lean implementations. After this session, participants will be able to: • Support their organization’s implementation of Lean methods through culture change and application of innovation concepts and tools • Recognize opportunities to apply creative thinking in a more deliberate way within the context of a chosen improvement approach such as Lean • Describe how Virginia Mason has integrated innovation and Lean to accelerate its quality and safety improvement efforts Chafetz, L., JD, SVP, Virginia Mason Medical Center; Phillips, J., Director of Innovation, Virginia Mason Medical Center; Plsek, P., Consultant, Paul E. Plsek & Associates, Inc.; Tufano, A., Faculty, Virginia Mason Institute M5: Advanced Statistical Process Control in Health Care M Crystal Ballroom, Salon K-M This Minicourse will cover several issues in statistical process control (SPC) in health care. After a brief review of the basics (types of data, basic control charts, choice of chart, interpretation), the presenters will discuss how to assess performance (such as how to detect important changes), and how to improve performance, especially with respect to sample size, chart design, and exponentially weighted moving average (EWMA) and cumulative sum control (CUSUM) charts. Case studies will be presented that illustrate both issues in measurement error (theory, concepts, impact, action) and, more specifically, common errors in health care applications of SPC. After this session, participants will be able to: • Assess and improve the effectiveness of SPC tools • Use rare event charts, EWMA charts, and CUSUM charts • Avoid common errors and mistakes in applying SPC to health care Jordan, V., PhD, Director, Quality Measurement and Engineering, University of Texas MD Anderson Cancer Center; Benneyan, J., PhD, Professor, Northeastern University; James, B., MD, Chief Quality Officer, Intermountain Healthcare M6: Courage in Health Care: Leading from Within F Grand Ballroom, Salon 1-2 Change calls for personal and communal courage. This program introduces current and emerging health care leaders (Open School students encouraged) and patient advocates to the Center for Courage & Renewal’s principles and practices for leading from within. The Courage & Renewal® approach supports 25th Annual National Forum on Quality Improvement in Health Care professional renewal and leadership integrity. Attendees will learn Parker Palmer’s “Habits of the Heart,” which help leaders and groups hold tension in generative ways and support the building of relational trust and responsible decision-making. • Apply lessons from system-, national-, and international-level examples to their spread efforts After this session, participants will be able to: • Identify three ways to foster engaged listening and attention • Implement protocols for reflection and connection in groups • Name the “Habits of the Heart” that support relational trust in effecting positive change M9: Making High-Reliability Health Care Happen Schall, M., Senior Director, IHI; Mate, K., MD, Vice President, IHI; Haraden, C., PhD, Vice President, IHI; McCannon, J., Faculty, IHI Crystal Ballroom, Salon N Kinkead, L., Consultant, The Collabrium; Lenarz, L., MD, Medical Director, Clinician Professional Development, Fairview Health Services M7: Data Sanity: Leadership Catalyst to Transformation Crystal Ballroom, Salon G Poor use of data remains a major—and invisible— source of waste. What if executives and middle managers facilitated transformation by spending 50 percent less time in meetings pouring over routine published operational and financial data (60 to 80 percent of which is waste?) This session will teach “data sanity”—an organization-wide everyday language used in conjunction with results-oriented facilitation skills. This innovative approach to leadership integrates improvement into the cultural DNA and encourages physician participation. After this session, participants will be able to: • Identify the key elements of data sanity that everyone needs to be taught—especially the common and special causes of variation • Apply four techniques to focus vague problems, reduce cultural defensiveness, and encourage appropriate participation • Apply basic results-oriented coaching skills and cultural psychology to integrate data sanity effectively as an organizational language for continual improvement Balestracci, D., Statistician and Quality Improvement Specialist, Harmony Consulting, LLC Several organizations are working to develop effective strategies and tools to adapt lessons from high-reliability organizations that can be used effectively in health care. For hospitals and health systems to achieve high-reliability, they will need to ensure three critical components. These are: A leadership commitment to achieve the ultimate goal of zero patient harm; a strong and vibrant culture of safety; and the adoption and widespread deployment of highly effective process improvement tools. This Minicourse is designed for Chief Medical Officers and Chief Quality Officers, who are critical leaders on the journey to high reliability health care. Attendees will hear from faculty who are deeply engaged in this work and will share their experiences and facilitate an interactive discussion. After this session, participants will be able to: • Discuss the importance of leaders as agents of change on the journey toward high reliability • Share lessons learned from those who are working to achieve high reliability • Articulate specific actions they can take within their organizations to make progress toward high reliability Chassin, M., MD, President, The Joint Commission; Yates, G., MD, President, Sentara Quality Care Network and Healthcare Performance Improvement, LLC, Sentara Healthcare; James, B., MD, Chief Quality Officer, Intermountain Healthcare; Berwick, D., MD, President Emeritus and Senior Fellow, IHI; O’Shaughnessy, P., DO, Senior Vice President of Medical Affairs and Chief Medical Officer, Catholic Health Services of Long Island; DuPree, E., MD, Chief Medical Officer and Vice President, Joint Commission Center for Transforming Healthcare M8: Going Full-Scale: Taking a Fresh Look at Approaches to Spreading Improvements M10: How to Be a Great Change Agent M Crystal Ballroom, Salon A-C It’s tough being a change agent, particularly when other people don’t want to change. Yet big change happens in health care organizations only because of heretics: Passionate people who are willing to take responsibility for change. Such individuals support organizational goals, but also want to change existing thinking and practice and improve care for patients. This session provides a toolkit for surviving and thriving as a change agent. Crystal Ballroom, Salon D Scale-up thinking—finding and overcoming the infrastructure issues that arise during spread— gives us an added dimension to consider in leading the large-scale spread of improvements. Whether change is spread at a facility, system, community, regional, or national level, crucial tasks in a successful spread effort include establishing clear aims, engaging leaders, and identifying the tools, resources, and processes needed to motivate adopters and support implementation of the improvement at each stage in the development of the change. In this session, examples from large-scale spread efforts will be used to illustrate the power of scale-up thinking. After this session, participants will be able to: • Build scale-up thinking into the design of large-scale spread initiatives After this session, participants will be able to: • Identify and practice tactics for being an effective change agent • Build a toolkit of powerful approaches to enable change • Connect with and learn from other change agents Bevan, H., PhD, Chief of Service Transformation, NHS Improving Quality; Varnam, R., MD, PhD, Primary Care Physician, NHS Institute for Innovation and Improvement M11: Integrate Words and Numbers to Improve Action F Grand Cayman/Puerto Rico The integration of both qualitative and quantitative data can provide a more inclusive and useful understanding of a system, subsystem, or project. With better understanding, a more consequential story—and hence better informed action—can be developed. In this interactive session, participants will explore processes to support effective collection and analysis of qualitative data, using modified methods from qualitative research to synthesize this information from patients with traditional quantitative data. This helps to develop a more meaningful and constructive story. After this session, participants will be able to: • Identify ways to effectively collect and analyze qualitative feedback from patients • Use modified methods to integrate the findings of qualitative research with traditional quantitative data to construct a meaningful story Butts, S., Improvement Advisor, Butts-Dion Consulting, Inc.; Taylor, J., Improvement Advisor, IHI; Crowe, G., RN, Principal, Hamilton Consulting, LLC M12: Managing Improvement at the Front Line Grand Ballroom, Salon 11 Although front-line managers play a critical role in supporting, executing, and sustaining improvement and patient safety, many may lack the necessary fundamental improvement competencies and are burdened with unanticipated daily problems, excessive demands, and inefficient systems. In this session, participants will acquire tools to help them manage time, solve problems more effectively, and enhance their skills in effective measurement systems and improvement processes. After this session, participants will be able to: • Identify the foundational tools that managers must have to support improvement • Describe two measurement approaches to tracking improvement progress • Use new skills in coaching and collaborative leadership models Williams, D., PhD, Improvement Advisor, TrueSimple Consulting; Munch, D., MD, Executive Vice President, Healthcare Performance Partners M13: See, Solve, Share, and Lead: Methods for Achieving Excellence F Grand Ballroom, Salon 12-14 This Minicourse will introduce the capabilities that underpin the sustained competitive advantage of high-velocity organizations. Participants will learn to see (identifying process deviations in (continued on next page) What are you talking about during your Minicourse? Tweet it using #IHI25Forum 17 PRE-CONFERENCE Monday DECEMBER 9 Minicourses 8:30 AM-4:00 PM flagging systems before they reach failure points); solve (addressing, rectifying, and converting failures into sources of superiority); share (understanding the internal dynamics of a high-velocity organization to ensure knowledge spread for relentless improvement); and lead (identifying the critical skills and leadership roles in high-velocity organizations.) After this session, participants will be able to: • Implement “see, solve, share, and lead” methods for performance improvement • Differentiate between complicated and complex dynamics in high-velocity organizations Downes, T., Consultant Geriatrician, Sheffield Teaching Hospitals; McIlwain, T., MD, Vice President, Quality and Process Improvement and Chief Medical Officer, St. Luke’s Episcopal Hospital; Spear, S., Senior Fellow, Massachusetts Institute of Technology M14: Systems Simulators: The Theory and Practice M St. Thomas/West Indies There are simulators for readmissions, spread, and access, and all of them help teams test out various change strategies and discover the likely impact and result they can expect if they follow the strategy. These simulators are crucial when the variables are complex and interdependent, and when results can be expected only at some time and distance from the implementation of the change strategies. Systems simulators are new to health care and are becoming an essential part of large complex systems change. After this session, participants will be able to: • Describe the theory of gaming and simulation and how it relates to social learning • Assess different gaming and simulation methods and scope out ideas for their own computer-based simulation or game • Identify, test, and critique the ways in which systems simulation can speed up the implementation of systems improvement Fraser, S., PhD, Independent Consultant, Sarah Fraser & Associates Ltd; Henriks, G., Chief Executive of Learning and Innovation, The County Council of Jönköping; Thompson, K., Managing Director, Bioteams Design 18 Triple Aim for Populations • Draw lessons from VMMC’s experience that can be applied to their own organization M15: Designing for Health and What Matters Most: Value-Based, Whole-Person Systems of Care Silversin, J., DMD, DrPH, President, Amicus, Inc.; Kaplan, G., MD, Chairman and CEO, VMMC Grand Ballroom, Salon 9-10 M17: IHI’s Approach to Reducing Avoidable Readmissions In this creative course, participants will design community centers of health that honor, enhance, and produce value through robust primary care team relationships, building on Intermountain Health’s successful and sustained redesign of primary care through mental health integration (MHI), IHI’s Triple Aim, and the development of integrated care for dually eligible beneficiaries. Participants will create a framework that defines value by incorporating an understanding of what really matters to individuals, their families, and their communities; describes the leadership needed to deliver this value; and provides approaches to practical measurement of success in meeting those values. Participants will engage in a collective social network activity that creates novel designs for sustainable, local, and affordable social centers of health, focusing on efficient, evidence-informed care processes, realigned financial incentives, and engagement of patients, families, and communities. They will also create a set of implementation and measurement tools to apply to their own local health delivery transformations. Grand Ballroom, Salon 8 After this session, participants will be able to: • Create a set of values and outcomes that make the most difference in the lives of individuals and communities • Define the delivery system and societal costs that measure the value of enhanced quality • Build a framework for measurement that rewards the quality of primary care through relational networks Rutherford, P., RN, Vice President, IHI; Coleman, E., MD, Director, Care Transitions Program, University of Colorado Anchutz Medical Center; Nielsen, G., Faculty, IHI Reiss-Brennan, B., Mental Health Integration Director, Intermountain Healthcare; Laderman, M., Research Associate, IHI; Boudreau, K., MD, Chief Medical Officer, Boston Medical Center HealthNet Plan This Minicourse will address all the components of excellent, efficient services for the last years of a long life, which can be marked by multiple chronic conditions, progressive disability, high costs, and fragile balance with the environment. Participants will learn how to identify and enroll frail persons, adapt services to match their needs, develop and optimize individual care plans, integrate social services and health care, and monitor and manage the local care system. This session will include demonstrations, resources, toolkits, production system redesign, advocacy, and practical examples. M16: Engage Physicians to Transform Care Crystal Ballroom, Salon J Improvement cannot be embedded into an organization’s culture without the active engagement of physicians. In this Minicourse, we will describe a comprehensive model for successful physician engagement, including the role of a new physician-organization compact, and explain how participants’ organizations could adopt it. Presenters will also share relevant perspectives from the ongoing efforts at Virginia Mason Medical Center (VMMC) to improve care and efficiency through implementation of the Virginia Mason Production System, illuminating the critical role of physicians in this work. After this session, participants will be able to: • Describe how urgency, shared vision, change sponsorship, a compact (reciprocal expectations between doctors and their organization), and a comprehensive method facilitate physician engagement in improvement efforts • Address the loss of autonomy that often blocks physician engagement From 2009 until 2013, IHI led a groundbreaking, multi-state, multi-stakeholder initiative: STate Action on Avoidable Rehospitalizations (STAAR). The aim was to dramatically reduce rehospitalization rates in states and regions by supporting quality improvement efforts at the front lines of care while simultaneously working in parallel with state leaders to initiate systemic reforms to overcome barriers to improvement. This Minicourse will highlight the STAAR Initiative’s progress to date in Massachusetts, Michigan, and Washington. After this session, participants will be able to: • Describe the STAAR Initiative’s two concurrent strategies to reduce avoidable rehospitalizations • Identify common problems that contribute to rehospitalizations as well as promising approaches to reducing them • Compare and contrast case studies from sites that have implemented improvements to dramatically reduce avoidable rehospitalizations M18: Living Well While Old and Frail — at Lower Cost Key Biscayne After this session, participants will be able to: • Test the best tools and strategies for identifying and serving frail elders • Construct monitors of quality and cost relevant to this population • Test the business models and policy changes that enable improvement while also applying insights to building a plan for their home community Lynn, J., MD, Director, Center for Elder Care and Advanced Illness, Altarum Institute; Deremo, D., RN, President and CEO, Hospice of Michigan; Brummel-Smith, K., MD, Chair, Department of Geriatrics, Florida State University College of Medicine 25th Annual National Forum on Quality Improvement in Health Care M19: Moving from Health Care to Population Health Harbor Beach Inspired by dramatic improvements in Scottish patient safety, the Scottish government has launched the Early Years Program with the aim of improving developmental outcomes for children under age five. Engaging the civil sector, private businesses, and charity organizations, this program in population health improvement targets education, early identification in general practices, and community rehabilitation. This session will explore the lessons learned when practitioners make the leap from focusing on improving health care to improving population health. After this session, participants will be able to: • Identify the key elements of a program that aims to improve population health and well-being in a population • Work with others to develop improvement plans for their organization • Develop innovative ideas about moving improvement techniques beyond health care Leitch, J., Clinical Director, Quality Unit, Scottish Government Health Department; Bennett, B., Principal Advisor, Improvement Science Consulting; Gray, R., Head of Safety in Healthcare, Scottish Government; Bell, D., Early Years Unit Head, Scottish Government; Laing, S., Deputy Director, Early Years Project, Scottish Government; Lewis, N., Director, IHI Person- and Family-Centered Care M20: Beyond the Patient-Centered Medical Home: Southcentral Foundation’s Nuka System of Care Grand Ballroom Salon 4-6 Southcentral Foundation (SCF) has been an NCQA patient-centered medical home, Level 3 (highest level), since 2010 and was awarded the Malcolm Baldrige National Quality Award in 2011. Find out why many medical systems nationally and internationally are now looking to the SCF Nuka System of Care as a way to transform a whole system of care. With a foundation built on the transfer of control and power to the patient, long-term personal relationships backed by full and open access, integration of the mind and body, and a commitment to measurement and quality, the Nuka System has resulted in sustained, dramatic, and documented improvements over 15 years. Utilization of emergency departments and specialty care has dropped in half, hospital days have dropped by over 40 percent, and health outcomes as well as customer and staff satisfaction have dramatically improved. This Minicourse will describe how SCF is moving beyond the concept of the patient-centered medical home and will present the continuing story of whole system transformation. After this session, participants will be able to: • Review the transformational journey of an entire health care system from physician-centered to patient-centered to customer-owned • Describe the systematic approaches to creating and sustaining ongoing relationships between a patient and physician that go beyond access and communication • Identify what is required to move beyond a patient-centered medical home to a customer-owned health care system Gottlieb, K., President and CEO, Southcentral Foundation; Eby, D., MD, Vice President of Medical Services, Southcentral Foundation Patient Safety M21: A Sociotechnical Framework for Driving a Culture of Safety, Clinical Excellence, Continual Learning, and Improvement Vinoy The pursuit of excellence in health care requires a systematic framework that supports effective assessment, intervention, measurement, and sustainable improvement. The areas of patientand family-centered care, leadership, safety culture, teamwork, reliable process, and systems of learning must all be addressed to achieve sustainable improvement. This Minicourse will provide participants with a framework that can be applied at a clinical-unit or service-line level, whether in a hospital or a large health system. Faculty will also offer practical tools and techniques as well as examples of effective application that participants can apply to their own organization. After this session, participants will be able to: • Describe the components of a framework for operational excellence • Articulate to clinical and administrative leaders their responsibilities as leaders of teams and overseers of learning and improvement • Make the link between clinical outcomes and culture—including cultural measurement— and discuss how to use measurement to effect change Frankel, A., MD, Principal, Pascal Metrics Inc.; Leonard, M., MD, Principal, Safe & Reliable Care, LLC and Adjunct Professor of Medicine, Duke University School of Medicine M22: Are You Ready for the Call? Serious Event Response M New York/New Orleans Something terrible has just happened in your organization. Perhaps a medication error has caused the death of a patient, or numerous patients have been exposed to contaminated equipment. Are you prepared for such a serious event? This interactive, case-based session will be led by faculty with a wide range of experience in administration, patient safety, risk management, the legal issues involved in serious events, and advocacy for patients and caregivers. Participants will be able to develop a comprehensive response plan, including caring for the first and second victims of serious events. After this session, participants will be able to: • Assess their organization’s level of preparedness to handle a serious event • Develop an effective and comprehensive crisis management plan that ensures respectful treatment of patients as well as families and caregivers Stewart, K., Clinical Director, Clinical Effectiveness Unit, Royal College of Physicians; Sadler, B., JD, Senior Fellow, IHI; Deen, J., RN, JD, Patient Safety Officer, Catholic Healthcare Partners; Kenney, L., President and Founder, Medically Induced Trauma Support Services M23: Protecting Children from Harm P Aruba/Bahamas Pediatric patient safety, a developing field in health care, presents different challenges from those found in adult-focused settings. Fortunately, there is a growing knowledge base on which to base interventions. Understanding the barriers to the provision of safe care for children is key. In this session, leaders from Pediatric International Patient Safety and Quality Community (PIPSQC) will present the latest theories on safety in child services, from the community to the hospital, focusing on child- and family-centered care. After this session, participants will be able to: • Identify the risks facing children in health care • Develop a framework for pediatric patient safety and access tools that can be used in safety programs • Utilize novel ways to protect children, led by parents and caregivers Lachman, P., MD, Associate Medical Director and Consultant in Service Redesign and Transformation, Great Ormond Street Hospital for Children NHS Trust; Micalizzi, D., Pediatric Advocate, Advisor, and Educator, The Task Force for Child Survival and Development; Scanlon, M., MD, Knowledge and Solutions Architect, Medical College of Wisconsin; Taitz, J., MB ChB, Director of Medical Services, Royal North Shore Hospital M24: Rethinking Critical Care: Getting in Action M Key Largo Many patients in intensive care units require sedation, mechanical ventilation, and other life-saving interventions that can lead to complications. Oversedation, immobility, and delirium are a triple threat—separate yet reinforcing complications that can lead to long-term patient harm. Drawing from IHI’s popular two-day seminar with our world-class faculty, this session will help participants take action to reduce sedation, increase delirium detection, and improve mobility for critically ill patients. After this session, participants will be able to: • Explain methods to monitor for delirium, agitation, confusion, and sleep using the Confusion Assessment Method for the ICU (CAM-ICU) and the ABCDE (awakening, breathing, coordination and choice of sedation, delirium, and early mobility/exercise) technique • Identify new techniques to reliably enhance patient mobility earlier in the care process McCutcheon Adams, K., LICSW, Director, IHI; Ely, E., MD, Physician Scientist, Intensivist, Vanderbilt University; Spuhler, V., RN, Nurse Manager, Intermountain Medical Center; Clemmer, T., MD, Director, Critical Care Medicine, LDS Hospital 19 Monday SPECIAL EVENTS Lean Health Care: John Kim and Associates (JKA) Vendor Presentation 4:45 PM – 5:15 PM Palms Foyer Classroom Lean Health Care: Hospitals, Physician Practices, and Health Plans After 15+ years implementing Lean, JKA has emerged an industry leader in the integration of Lean principles and development of supporting management systems in health care. Respecting differences in culture, objectives, and process has been the key to customized approaches to improve access, satisfaction, quality/safety, and financial performance in physician practices, hospitals, health system and health plans. Attend this session to learn more about JKA and how we can help you. Welcome Reception 3:30 PM – 6:30 PM Palms Ballroom, Exhibit Hall IHI Fellowships Q&A Session 4:15 PM – 5:00 PM IHI Booth #301, Exhibit Hall Join current and past IHI fellows for an informal Q&A session about their IHI fellowship experience. 6th Annual IHI Open School Chapter Congress S (sponsored by Kaiser Permanente) 4:30 PM – 7:30 PM G Gaylord Palms, Sun Ballroom C The IHI Breakthrough Series College Q&A Session 5:15 PM – 6:00 PM IHI Booth #301, Exhibit Hall Come and talk with the IHI Breakthrough Series College faculty about the design and content of the Breakthrough Series College. We will share with you what makes for a great Collaborative topic and the kind of set-up you need if you are considering running a Collaborative. Faculty and Student Reception S 7:00 PM – 9:00 PM G Gaylord Palms Emerald Bay Plaza This networking event is offered specifically for IHI faculty, National Forum presenters, and health professions students. 20 25th Annual National Forum on Quality Improvement in Health Care CONFERENCE DAY 1 Rapid Fire Workshops 10 minutes, 10 slides Grand Ballroom, Salon 4-6 Tuesday DECEMBER 10 keynote one 8:00 AM – 9:00 AM In these fast-paced sessions, presenters will have 10 minutes to present 10 slides on the topics listed below. RFA: Lessons Learned from Spread and Large Scale Change Initiatives Moderator: Schall, M., Senior Director, IHI Presenters: Schilling, L., RN, National Vice President, Healthcare Performance Improvement, Kaiser Permanente; Davies, M., National Director, VHA Systems Redesign, Veterans Health Administration; McCannon, J., Faculty, IHI special interest keynotes A1: Removing Waste from Health Care: Lessons from the Choosing Wisely Campaign and the Right Care Alliance 9:30 AM – 10:45 AM Cypress Ballroom 3 Cypress Ballroom 3 RFB: Health Systems as Employers Grand Ballroom, Salon 4-6 Maureen Bisognano President and CEO, IHI Moderator: Coye, M., Chief Innovation Officer, UCLA Health System Presenters: Wozney, B., MD, Medical Director for Ambulatory Quality and Informatics, Bellin Health System; Bernard, P., CEO, Bon Secours Health System; Skootsky, S., MD, Chief Medical Officer, University of California Los Angeles Health Care Storyboard Walkarounds National Forum Orientation 7:00 AM – 8:00 AM Crystal Ballroom, Salon G If you are new to the National Forum, we suggest that you attend one of the National Forum orientation sessions to help you navigate through the program and devise a personal learning plan. Participation in National Forum orientation is free. Cypress Ballroom 1 Daniel Wolfson, Executive Vice President & COO, ABIM Foundation Shannon Brownlee, Senior Fellow, Lown Institute Vikas Saini, President and CEO, Lown Institute B1: Global Lessons in Improvement from Around the World 11:15 AM – 12:30 PM Cypress Ballroom 3 NEW! Take a walking tour of some of the exceptional storyboards submitted this year. Each session will include a moderator and storyboard presenters will stand beside their boards to answer questions. SWA: Identifying and Combatting Sepsis Moderator: Grandhi, R., Student, University of Cincinnati College of Medicine Presenters: : Vovan, A., MD, Director of Clinical Care, Hoag Memorial Hospital Presbyterian; Barnes-Daly, M., RN, Regional Clinical Initiative Lead, Sutter Health; Grbavac, B., RN, Regional Supervisor, Performance Improvement, Franciscan Alliance; Stromoski, D., RN, Sepsis Coordinator, UPMC Shadyside SWB: Patient Safety Initiatives Moderator: Lichkus, J., Student, Boston University School of Medicine and Harvard School of Public Health Presenters: Bock, K., MD, Director, Clinical Information Systems, North Shore-LIJ; Brockmeyer, D., MD, Medical Director, Anticoagulation Service, Beth Israel Deaconess Medical Center; Allen-Dicker, J., MD, Physician, Mount Sinai Medical Center; Smith, P., MD, Chief Medical Officer, Tenet Healthcare Corporation Nigel Crisp, Former Permanent Secretary in Health, United Kingdom and Former Chief Executive, National Health Service England Moderating a panel including: Göran Henriks, Chief Executive of Learning and Innovation, The County Council of Jönköping Wim Schellekens, MD, Strategic Advisor, The Hague Area, The Netherlands Jason Leitch, Clinical Director, Quality Unit, Scottish Government Health Department Haidee Davis, General Manager, Ko Awatea, Counties Manukau District Health Board Sodzi Sodzi Tettey, MD, Executive Director, Department of Health, National Catholic Secretariat, Ghana Mike Richmond, Chief of Clinical Affairs, Hamad Medical Corporation, Qatar 21 CONFERENCE DAY 1 A3/B3: Clinical and Cost Improvement for Population Health Crystal Ballroom, Salon D Tuesday DECEMBER 10 A workshops 9:30 AM – 10:45 AM B workshops 11:15 AM – 12:30 PM All A workshops repeat during B workshops except for special interest keynotes. When clinical decision support is integrated into health care information technology systems, both cost and quality outcomes can be improved. Under the health care reform law, evidence-based health care is considered an important strategy for developing accountable care organizations (ACOs) and patient-centered medical homes (PCMHs). In this workshop, we will discuss how clinical decision support can help organizations improve the cost and quality of care and build the clinical infrastructure for ACOs and PCMHs. After this session, participants will be able to: • Identify the potential of evidence-based clinical decision support for improving cost and quality outcomes across the continuum of care • Describe the potential role of clinical decision support in the creation of ACOs and PCMHs Weingarten, S., MD, Senior Vice President and Chief Clinical Transformation Officer, Cedars-Sinai Medical Center; Classen, D., MD, Associate Professor of Medicine, Senior Partner and Chief Medical Officer, Pascal Metrics, Inc. A4/B4: Deliver Value with Volume and Operating Room Efficiencies Harbor Beach A/B workshops Quality, Cost, and Value A2/B2: A Year in the Life: Living with Long-Term Care Grand Cayman/Puerto Rico The “Year in the Life” program for patients with chronic obstructive pulmonary disease (COPD) provides a methodology to increase value in the care provided to long-term-care patients at scale. Using an educational approach and linking it to improvement cycles and better information systems, we saw higher quality at lower system cost over one year in a population of COPD patients across 188 general practices in four boroughs. This workshop will discuss the key to that success: Empowering patients by increasing uptake of self-management plans and using a care navigation tool. After this session, participants will be able to: • Use technology to identify service inefficiencies • Develop, implement, and track service improvements Roberts, C., MD, Consultant, Barts and the London NHS Trust; Meaker, R., Director of Innovation, Redbridge CCG In the current health care environment, providers must quickly develop new models of care delivery that increase both volume and value. We can create value by delivering exceptional care experiences as well as outcomes through a patient-focused care center (PFCC), which we build by co-designing the care experience with patients, families, and providers. In this workshop, we discuss how to manage and focus all required resources, develop high-performance care teams, and design treatment through a full cycle of care. After this session, participants will be able to: • Deliver both value and volume to build their own PFCC • Improve clinical and operational outcomes (including operating room efficiencies) while decreasing waste and cost by focusing on the experience rather than the service line DiGioia, A., MD, Medical Director and Surgeon, PFCC Innovation Center, University of Pittsburgh Medical Center A5/B5: Fast-Track Surgical Recovery Crystal Ballroom, Salon P-Q Participants in this workshop will learn how a protocol to send postsurgical esophagectomy patients to a telemetry floor with aid from MLPs, rather than to the surgical intensive care unit, resulted in a mean length of stay decrease of seven days. Postsurgical complications also showed a significant improvement. The cost savings will be compared for the pre- and post-intervention time frames. After this session, participants will be able to: • Illustrate the potential for cost savings 22 through improved postsurgical protocols • Classify the savings potential for the eligible and ineligible costs incurred in improving patient outcomes Schaub, D., Senior Statistical Applications Analyst, University of Texas MD Anderson Cancer Center; Shewale, J., Graduate Research Associate, University of Texas MD Anderson Cancer Center A6/B6: Improving Quality and Reducing Costs: QUEST Year Five M Grand Ballroom, Salon 3 During this session, participants will learn how more than 330 hospitals participating in the collaborative methodology of the QUEST initiative have improved quality—in terms of evidencebased care, mortality, safety, readmissions, and patient experience—while safely reducing costs. These hospitals have avoided more than 30,000 acute care deaths while reducing costs by more than $7 billion. After this session, participants will be able to: • Describe the six areas of focus of the QUEST initiative • Identify five tactics implemented by high-performing QUEST hospitals to achieve top performance • Explain the value of transparent measurement and QUEST’s collaborative methodology in driving improvement across the participating hospitals Scott, C., RN, Service Line Vice President, Quality and Safety, Premier, Inc.; Parsons, T., Vice President, Tennessee Hospital Association A7/B7: Nurse-Sensitive Measures and Value-Based Purchasing F Grand Ballroom, Salon 12-14 The success of hospitals’ pursuit of safe, effective, efficient, timely, and patient-centered care depends in part on their ability to engage and use nursing resources effectively. In this workshop, we will discuss this effort at North Shore-LIJ, where structures and processes were adapted to empower registered nurses with a well-coordinated, multidisciplinary team approach to patient care delivery. Excellent outcomes were achieved, as reflected in nurse-sensitive indicators that surpassed the national benchmark. The successful implementation of a bundle of cost-effective, evidence-based practices resulted in enhanced safety and quality outcomes at North Shore-LIJ and increased revenues through avoidance of $43 million in costs. After this session, participants will be able to: • Utilize structures and processes to enhance patient experience, safety, and quality while bending the cost curve • Implement cost-effective, evidence-based practices to achieve excellent outcomes in nurse-sensitive indicators Scanlon, K., RN, Chief Nursing Officer, North Shore University Hospital, Deputy Chief Nurse Executive, North Shore-LIJ; Memoracion, E., Director, Patient Care Services, Long Island Jewish Medical Center; White, M., Senior Vice President and Chief Nurse Executive, North Shore-LIJ 25th Annual National Forum on Quality Improvement in Health Care A8/B8: Leading the Way to Better Care: Florida’s Quality Journey A10/B10: Personal Mastery for Transformational Leadership S Sawgrass Crystal Ballroom, Salon H Five years ago, Florida’s hospitals set out to improve care across the state. Working together, they developed first-of-a-kind initiatives to reduce readmissions, improve surgical outcomes, and prevent infections. Today these efforts have resulted in significant improvement and cost savings: 11.2 percent reduction in readmissions, 10.5 percent reduction in complications, 38 percent drop in surgical site infections, 41 percent drop in CLABSI, 37 percent reduction in CAUTI, and at least $27 million in savings. Participants in this workshop will learn how Florida’s hospitals collaborated, innovated, and built a statewide culture of quality. Transformational change depends on how fast and how far people shift their habits, role patterns, and ways of thinking and relating. Emotional tension and resistance are human and ubiquitous constraints. Within such stress and complexity, leaders are faced with the difficult task of simultaneously managing their own reactions, standing firm on decisions, and engaging others with individual consideration. In this workshop, faculty will present methods to enhance “personal mastery”—learning the way to desired results and creative relationships. After this session, participants will be able to: • Describe how Florida’s hospitals worked together to significantly improve care while reducing costs across the state • Identify the key lessons learned over the five years Florida’s hospitals worked together on nation-leading programs to reduce readmissions, complications, and infections • Develop actionable steps for collaboration around quality improvement in their own state Greene, H., President and CEO, Baptist Health Improvement Capability A9/B9: Getting by with a Little Help from… Students? S Grand Ballroom, Salon 9-10 More and more, students are joining quality improvement efforts in their local health care settings. Future nurses, physicians, and administrators are looking at processes and data with fresh ideas. Are they helping? Or are they just another hand to hold? In an innovative, debate-style workshop, listen to both sides of the argument as professionals reveal their experiences working with students from different health care disciplines. Join in the spirited arguments—which will be moderated by the IHI Open School advisors—and share your feedback about working with the next generation. Have you been inspired? Frustrated? In this workshop, participants’ input can help the conversation as we define best practices that will be actionable immediately after the conference. After this session, participants will be able to: • List at least two ways in which students can be helpful in quality improvement efforts in a health care setting • Defend why it’s important for their organization’s future to have students involved in its quality improvement efforts • Recognize an innovative way to present information to an audience of health care professionals and students Madigosky, W., MD, Director, Foundations of Doctoring Curriculum, University of Colorado Anchutz Medical Center; Moses, J., MD, Director of Safety and Quality, Department of Pediatrics, Boston Medical Center After this session, participants will be able to: • Explain how to identify and respond effectively to reactions in oneself and others that may interfere with progress • Identify key elements for facilitating creativity in order to change habits and patterns • Define ways to exercise authority that also help to preserve positive engagement Baker, N., MD, Principal, Neil Baker Consulting and Coaching A11/B11: Please, No More Red, Yellow, and Green M Crystal Ballroom, Salon N In all organizations, it’s vital that senior leaders and board members are able to view key measures of the organization’s status in ways that further their ability to ask pivotal questions, draw valid conclusions, and make insightful decisions. Often senior leadership is presented with data for system-level measures in a tabular summary or other relatively flat ways, such as color-coding, that are of limited utility for learning. Participants in this workshop will learn the latest in how to display measures for senior leaders more powerfully and effectively. After this session, participants will be able to: • Identify why tabular or color-coded methods of displaying key measures to senior leaders are inadequate for learning and improvement • Identify the key design elements of a great vector of measures (VOM) • Analyze a VOM Murray, S., Improvement Advisor, CT Concepts; Provost, L., Statistician, Associates in Process Improvement; Penner, J., Executive Director, Mecklenburg Emergency Medical Services Agency A12/B12: Raising the Bar for Health System Boards Vinoy Too often, health organization boards of directors are “bit players” in the unfolding drama of health care strategy and governance. Traditional board roles, such as philanthropy, are no longer enough. In this session, presenters will pool their extensive experience in health care governance to describe the characteristics of a high-performance board. They will also discuss principal board roles, the qualities of ideal directors, ways to partner with management, and innovative board practices and policies. After this session, participants will be able to: • Identify the strengths and weaknesses of their board of directors’ approach to governance • Implement board activities or practices previously untried by their board • Assess the degree to which their current board members fit the organization’s needs Berry, L., PhD, Distinguished Professor of Marketing, Texas A&M University; Toussaint, J., MD, CEO, ThedaCare Center for Healthcare Value A13/B13: Spread and Network Methodology: IHI’s Best Practices Crystal Ballroom, Salon J At IHI, our work on collaboratives, campaigns, virtual courses, and sprints has taught us a lot about what works (and what doesn’t) when spreading content to a large audience. This session will provide an overview of network theories, suggested content sequencing principles, and spread tools that can assist content delivered in a structured and predictable way, facilitate proactive and meaningful communication and support, and maintain high energy across many large initiatives. After this session, participants will be able to: • Identify several strategies to develop and support a network • Describe practical tools that can be used to spread clinical elements throughout a network • Articulate several key network theories Duncan, K., RN, Faculty, IHI; DeBartolo, K., National Field Manager, IHI; Gunther Murphy, C., Director, IHI A14/B14: Nurse Billing: Spreading Initiatives in the Region F Anaheim This workshop will give participants ways to think about navigating the challenge of standardization of work across multiple regional clinics separated by many miles. Participants will learn to use the Gundersen Quality Improvement Toolkit, including basic quality improvement tools, through the specific example of instituting i-STAT testing of international normalized ratios (INRs) for chronic anticoagulation across three physically disparate clinics. Presenters will also address the hurdles of implementing nurse-only visits and billing. After this session, participants will be able to: • Show proficiency in using basic quality improvement tools • Extrapolate their experience in standard work into their own disparate departments • Discuss options for the implementation of nurse-only billing Gerhard, C., MD, Family Physician and Medical Director, Gundersen Health System; Krause, J., Chief Quality and Patient Safety Officer, Gundersen Health System What workshop are you enjoying? Tweet it using #IHI25Forum 23 CONFERENCE DAY 1 Tuesday DECEMBER 10 keynote two 3:15 PM – 4:15 PM Cypress Ballroom 3 Eric Weihenmayer World-class blind adventurer A15/B15: The Design, Development, and Use of Surveys in Health Care Settings • Develop a checklist of questions for any commercial vendor hired to gather survey data in their organization Lloyd, R., PhD, Executive Director, Performance Improvement, IHI; Williams, D., PhD, Improvement Advisor, TrueSimple Consulting; Luther, K., RN, Vice President, IHI A16/B16: What Can England Teach Us About Changing Health Care? Crystal Ballroom, Salon A-C Often we gain the greatest insights about our own health system by looking at other systems. In this workshop, spend 90 minutes with the English National Health Service (NHS), the biggest health system in the world. The NHS is implementing the most radical changes in its 65-year existence to position itself to deliver high-quality care within available resources. Participants will gain insights into possibilities for change in their own system by learning about the goals, methods, and approaches to change at the NHS. After this session, participants will be able to: • Identify strategies to bring care closer to patients’ homes, integrate care, and transform the dynamics between primary care and hospital care • Discuss how to redesign care on a systematic basis, building shared purpose, engaging patients and employees, and aligning incentives and pay for performance • Take home approaches, tools, and insights into transformation that they can apply in their own setting Bevan, H., PhD, Chief of Service Transformation, NHS Improving Quality; Fairman, S., Director of Business, Improvement and Research, Medical Directorate, NHS England Marco Island Historically, health care providers have used surveys to gather data that they have used primarily for marketing or publicity purposes. Over the past 10 years, however, there has been a dramatic shift in the objectives of survey research in health care settings. Today surveys are used less for marketing and more for demonstrating that the health care provider is listening to the voice of the customer. Most individuals developing surveys in health care organizations, however, have little or no formal training in survey design and methods, and the surveys they create are often poorly worded, use the wrong response scales, achieve a low response rate, and/or are analyzed and interpreted incorrectly. Management is left wondering why survey results don’t confirm their views of reality. This workshop will help participants turn this process around by presenting the critical elements of a well-designed survey that they can use in their organization. After this session, participants will be able to: • Describe the key steps in designing, implementing, and using surveys in health care settings • Design a roadmap for developing their own ad hoc surveys 24 Triple Aim for Populations A17/B17: An Innovative Approach to Delirium Management Crystal Ballroom, Salon E-F Hospitalized patients older than 65 who develop delirium have a 40 percent mortality rate over 12 months. One Kaiser Permanente facility responded to this challenge of improving outcomes for this population by applying existing industry best practices for the management of delirium. Through more effective use of relevant protocols, orders sets and medications, and comprehensive staff education, the patient care experience at this facility was improved. This workshop will outline the ways in which the Kaiser Permanente program resulted in a 23 percent reduction in average length of stay for patients with delirium. After this session, participants will be able to: • Describe the serious effects of delirium on the fragile, elderly population (morbidity, mortality, and increased length of stay) • Recognize the positive effect of a multidisciplinary, team-based approach to delirium care on the management of this disease process • Identify ways to begin implementation of a delirium management program Angel, C., MD, Kaiser Foundation Hospital; Brooks, K., MD, Psychiatrist, Kaiser Permanente Medical Group A18/B18: Psychiatric Emergency Department Patients: Special Handling Needed Chicago/Denver Although it is estimated that up to 25 percent of emergency department (ED) visits have a behavioral health component, this area of emergency care and operations is not as well developed as others. This workshop will discuss ways to address the special needs of the psychiatric patient by deploying an operations management approach: Training staff to “see through the patient’s eyes,” linking to community resources, and tracking improvements. Participants will learn how to use this approach to enhance overall flow and improve the patient and ED staff experience. After this session, participants will be able to: • Describe the challenges of serving behavioral health patients and discuss countermeasures • Identify the opportunities to improve the flow of behavioral health patients and enhance services to this population Nolan, K., Statistician, Associates in Process Improvement; Jensen, K., MD, Chief Medical Officer, BestPractices, Inc.; Crane, J., MD, Emergency Medicine Faculty, IHI A19/B19: Staying Alive: Computers to Keep Elderly Active St. Thomas/West Indies This presentation will describe Wisconsin’s community-based research—funded as an Agency for Healthcare Research & Quality (AHRQ) Center of Excellence in Active Aging Research—in 23 counties. This research used computer technology to help elderly (and family caregivers) reduce falls, scams, loneliness, and isolation, as well as improve driving safety and medication management. Faculty will present demonstrations of technology as well as a community organization approach they have used to build community engagement, including evaluation plans and pilot test results. After this session, participants will be able to: • Describe how to integrate several technologies to reduce the risk of an elderly person having to enter assisted living or a nursing home • Detail one approach to using community organization strategies to implement a Triple Aim project in multiple counties Gustafson, D., PhD, Director, Center for Health Enhancement Systems Studies, University of Wisconsin 25th Annual National Forum on Quality Improvement in Health Care A20/B20: Triple Aim Strategies for High-Risk, High-Cost Populations Grand Ballroom, Salon 7 Patients with complex needs often have difficulty getting the exact services they need and end up using expensive—but avoidable—services, including emergency department visits and hospitalizations. Health care organizations moving to models of cost accountability need robust strategies for serving the small percentage of patients who account for the majority of health care spending. Participants in this workshop will learn to apply IHI Triple Aim change ideas and measurement strategies to get better results for their high-risk, high-cost patients. After this session, participants will be able to: • Apply segmentation strategies to the identification of high-risk, high-cost patients • Develop action plans to better understand the needs of these patients from a person-centered viewpoint • Use “change concepts” that can be applied to this patient population to design the first set of tests to be implemented in a care redesign process Ramsay, R., Director of Community Care, CareOregon; Brooks, K., Project Manager, Triple Aim Initiatives, IHI Person- and Family-Centered Care A21/B21: Always Events®—Always as a Concept P Crystal Ballroom, Salon K-M Always Events (AEs) are evidence-based practices that ensure patient and family engagement. In this session, the guiding principles of AEs will be shared, and participants will be challenged to create an AE for their own setting. After this session, participants will be able to: • Describe the guiding principles of AEs and how they contribute to patient- and family-centered care • Develop a proposed AE outline for their own care setting Hayward, M., Lead, Patient and Family Engagement, IHI; Balik, B., RN, Senior Faculty, IHI, and Principal, Common Fire Healthcare Consulting; Carter, R., Senior Vice President, Planetree A22/B22: Heart Failure: Policy and People P Aruba/Bahamas Robert is 49 years old with end-stage cardiac failure. We have known him for 20 years but only recently started to see the world and our care through his eyes. In this interactive session, participants will also meet Robert and experience the care he has received through his eyes as he tells his story. We will then tie Robert’s story to the broader concept of reliable implementation of a strategic priority—heart failure care in Scotland. After this session, participants will be able to: • Understand heart failure from the patient’s perspective • Describe key steps in the reliable delivery of care to heart failure patients at both the micro and macro levels Labinjoh, C., MB ChB, Consultant, NHS Forth Valley; Mondoa, C., Consultant Nurse–Cardiology, NHS Forth Valley; Longmate, A., MB ChB, National Clinical Lead for Patient Safety, Scottish Government A23/B23: Why Some Doctors Don’t Listen and What You Can Do About It Crystal Ballroom, Salon G Today’s health care is replete with “cookbook medicine”: Doctors ordering tests rather than listening to each patient’s story. Using real-life narratives to illustrate the concepts, a physician, advocate, and author speaks about the importance of the patient story and the critical role it plays in getting to the right diagnosis and preventing medical error. The presenter will offer five practical suggestions to make sure the doctor listens and will illustrate them with interactive exercises to improve communication and ensure engagement. After this session, participants will be able to: • Describe the problems with today’s “cookbook” approach to medical care and how it came about • Discuss how important it is that the doctor or other health care provider hear the patient’s story to get to the right diagnosis • Take steps to become empowered to get their own doctor or health care provider to listen and help them get the medical care they deserve Wen, L., MD, Emergency Physician, Harvard Medical School A24/B24: A High-Quality Safe Medicines System for Patients M Grand Ballroom, Salon 1-2 Ten percent of hospital admissions result from adverse drug events, while five percent of inpatients suffer such a reaction. The result is both increased length of stay and higher readmission rates. By reengineering the medicines system, health care providers can enhance both quality and efficiency, with a return of about $12 for every $1.50 invested. This presentation will compare and contrast an integrated medicines system in Northern Ireland and a non-integrated medicines system in the USA. After this session, participants will be able to: • Describe how an integrated medicines management process can reduce harm and costs for acute care patients • Discuss how to establish such a system in their organization • Identify two ways in which patients can be engaged in this process in their organization A25/B25: Changing Practice: The Process to Reduce Seclusion Miami Reducing the use of seclusion and restraint is a critical issue for enhancing the safety of patients in mental health programs. One of the core strategies for reducing these unsafe practices is workforce development. St. Joseph’s Healthcare Hamilton undertook an evaluation project to examine staff skills in de-escalation strategies with patients, as a way to reduce the use of seclusion. This interactive presentation will include background on the developing science of de-escalation, skills assessment, and a content analysis of the simulations completed. After this session, participants will be able to: • Explain the science behind verbal de-escalation strategies so as to apply these lessons to their own setting • Practice using both “good” and “bad” de-escalation strategies in small groups • Implement a method to improve staff skills in the use of de-escalation strategies with patients Bieling, P., Director, St. Joseph’s Healthcare Hamilton, and Associate Professor, McMaster University; Madsen, V., Manager, St. Joseph’s Healthcare A26/B26: Goal Zero: South Carolina’s Commitment to Safety New York/New Orleans The South Carolina Safe Care Commitment (SCSCC) is a groundbreaking, ongoing initiative of 20 South Carolina hospitals from seven health systems, including academic medical centers, community hospitals, and a VHA facility. Participants will learn how the South Carolina Hospital Association and the Joint Commission Center for Transforming Healthcare partnered to employ the Center’s High Reliability Self-assessment Tool (HRST) and other innovative methods and measurements, resulting in strengthened systems, improved safety cultures, and better patient outcomes. After this session, participants will be able to: • Explain the methodology applied by the SCSCC to achieve dramatic reductions in preventable harm • Describe how the SCSCC helped shift hospital cultures of safety and the methods it used to embed these changes within and across hospital systems • Identify ways in which their organization can apply the learnings, methods, and tools to replicate the results and improvements achieved by the SCSCC Smith, C., RN, Black Belt, High Reliability Initiatives Director, The Joint Commission; Kirby, T., JD, President and CEO, South Carolina Hospital Association; Diller, T., Vice President, Quality and Patient Safety, Greenville Hospital System Scott, M., PhD, Head of Pharmacy and Medicines Management, Northern Health and Social Care Trust; Federico, F., RPh, Executive Director, Strategic Partners, IHI; Niemann, J., RPh, PharmD, Director of Pharmacy Services, Mercy Health Southwest Ohio What workshop are you enjoying? Tweet it using #IHI25Forum 25 CONFERENCE DAY 1 Tuesday DECEMBER 10 Storyboard Walkarounds 1:30 PM – 2:45 PM Cypress Ballroom 1 NEW! Take a walking tour of some of the exceptional storyboards submitted this year. Each session will include a moderator and storyboard presenters will stand beside their boards to answer questions. SWC: Engaging the Patient to Transform Care Moderator: Bhaskarabhatla, S., Researcher, Bhaskara Group Consultancy Presenters: Showecker, G., Clinical Application Coordinator, Chalmers P Wylie VA Ambulatory Care Center; Osborne-Stafsnes, J., Patient Engagement Program Manager, California Center for Rural Policy; Radel, K., Operations Director, Allina Health; Runcimen, E., RN, London Health Sciences Centre C workshops 1:30 PM – 2:45 PM C workshops do not repeat. special interest keynote C1: Fully Transparent Medical Records: Prospects and Problems 1:30 PM – 2:45 PM Cypress Ballroom 3 Tom Delbanco, MD, Professor of General Medicine and Primary Care, Harvard Medical School and Beth Israel Deaconess Medical Center, and Co-Director, OpenNotes Jan Walker, RN, Principal Associate in Medicine, Harvard Medical School and Beth Israel Deaconess Medical Center, and Co-Director, OpenNotes C workshops Quality, Cost, and Value C2: Co-Creating a Sustainable Healthy Tomorrow F Crystal Ballroom, Salon G Minnesota is pioneering a model of “co-creation” that fosters community conversations and actions around the IHI Triple Aim by bringing together clinicians, patients and citizens, and community stakeholders. This multi-phased project will support “accountable health communities” in which local, clinical, citizen leaders review their own data and set local goals and action plans based on the IHI Triple Aim. Through local leadership, community stakeholders address the issues associated with improving health, the experience of care, and the affordability of health care. After this session, participants will be able to: • Identify the strategies employed within select Minnesota communities to comprehensively engage clinicians, citizens, and community stakeholders seeking alignment around all aspects of the IHI Triple Aim • Detail the elements that are critical to success in building an accountable health community C3: Digital Health Technologies for Lower Costs and High Value F Crystal Ballroom, Salon K-M Digital health technologies (DHTs), wisely applied, are transforming many industries—including some areas of health care where recent innovations are causing rapid transformations and impact. These developments may be just the beginning, and this session will provide an overview of what is coming. Presenters from Scandinavia and the Veterans Health Administration (VHA) will discuss promising and proven DHTs; outline resources to help with implementation; and use examples to describe how to develop patient-centered care and estimate costs and returns on investment. After this session, participants will be able to: •List the main DHTs that will have an impact on their work, services, health systems, and health plans and identify areas of industry disruption from new DHT service combinations •Identify innovations to promote patient-centered care and co-service •Apply lessons and methods for implementation and cost and savings estimation to their own organization Ovretveit, J., PhD, Professor, Karolinska Institute C4: The Improvement Opportunity in Real-Time Location Systems F Harbor Beach This session describes Real-Time Location Systems (RTLSs) and the progressive expansion of their applications to improve health care quality and patient safety, reduce health care costs, and mitigate risk exposures. The most significant improvement opportunities are associated with applications that permit real-time tracking of hospital staff, patients, and movable equipment and that facilitate automation, monitoring, and improvement of clinical work flows in the emergency room, the operating room, and other key hospital locations. After this session, participants will be able to: • Describe three RTLS applications that address patient safety issues • Provide two examples of data-based improvement opportunities in a typical emergency department • Describe two ways in which RTLS supports significant cost reductions O’Leary, D., MD, President Emeritus, The Joint Commission; Chow, M., PhD, RN, Vice President, National Patient Care Services, Kaiser Permanente Magnan, S., MD, PhD, President and CEO, Institute for Clinical Systems Improvement (ICSI); Hanley, B., Vice President, Public Engagement, Twin Cities Public Television; Kershaw, S., Executive Director, Citizens League 26 25th Annual National Forum on Quality Improvement in Health Care Improvement Capability C5: Daily Huddles: Developing Situational Awareness M Crystal Ballroom, Salon N In any health care organization, the status of operations and ability to identify problems early is critical to safety concerns. During this session, experts will discuss how to implement and use daily check-ins at different levels of the organization to improve safety. After this session, participants will be able to: • Discuss how daily check-ins increase the resilience of an organization • List the steps necessary to implement daily huddles in their organization Federico, F., RPh, Executive Director, Strategic Partners, IHI; Yates, G., MD, President, Sentara Quality Care Network and Healthcare Performance Improvement, LLC, Sentara Healthcare C6: Engaging Front-Line Staff in Real-Time Improvement S Crystal Ballroom, Salon H Traditional suggestion systems can be ineffective in engaging staff and creating real impact. In this session, participants will hear an organizational case study on equipping front-line leaders with a different approach. Grounded in Lean and innovation principles, a staff idea system, and standardized leadership routines—including regular rounding and huddles—this approach enables staff to chip away at the rampant waste in health care. Presenters will describe design elements, examples, and critical success factors. After this session, participants will be able to: • Discuss the difference between a suggestion system and a Lean-influenced idea system • Describe daily leadership routines that engage staff in improvement • Identify critical success elements when implementing such an approach Phillips, J., Director, Center for Innovation, Virginia Mason Medical Center; Mann, S., RN, Director of Nursing, Virginia Mason Medical Center Patient Safety C7: Physician Culture Is a Solution, Not a Problem Grand Ballroom, Salon 7 Physician leadership is central to superb organizational culture and excellent outcomes. However, top-notch physician leadership will not spring from a disaffected, exhausted group of physicians. Invest in physician careers with a focus on selection, values, and leadership development. Use neuroscience research and courage (not off-the-shelf software) when designing recognition and discipline programs. Invite in the excellent, expel the toxic, and your reputation, business results, and progress on the IHI Triple Aim will improve. After this session, participants will be able to: • Identify the costs of physician disaffection • Use neuroscience to guide physician work-life interventions • Identify three steps to repel toxic behavior Fahy, P., MD, Consultant, Fahy Consulting C8: Privacy vs. Visibility in a Radial Nursing Unit Anaheim Quality health care begins long before patients and staff interact. It begins on the drawing board, where design decisions affect patient and staff well-being and efficiency for years to come. This workshop will present results from an investigation of whether moving the orientation of patient beds in a radial nursing unit affects patient satisfaction, falls, HCAHPS scores, and nurse time spent in patient rooms. Is the increased privacy for patients worth the decrease in patient visibility from the workstation? After this session, participants will be able to: • Identify the potential benefits and trade-offs of specific design decisions, such as the locations of patient headwalls and nursing station units • Make use of the impact of design decisions on a wide variety of factors, including patient satisfaction, patient fall rates, acoustical environments, emergency response times, and patient outcomes • Implement a model for evidence-based design decision-making, using research to drive specific design decisions Bosch, S., PhD, Director of Research, Gresham, Smith and Partners; Hiltonen, B., Senior Interior Designer, Gresham, Smith and Partners; France, L., RN, Nurse Manager, Florida Hospital Waterman; Worden-Kirouac, E., Interior Designer, Gresham, Smith and Partners C9: Reliability and Human Factors Sciences: Employing Engineering Concepts in the Development of High-Reliability Health Care Crystal Ballroom, Salon D This course introduces participants to the utilization of process reliability science and engineering concepts to improve health care. Faculty will provide examples from other industries where process reliability stabilized structure and led to reliable outcomes and high-performance culture. In exploring process reliability within the use of the IHI safety bundles, faculty will also illustrate a tangible return on investment with respect to cost and culture and introduce didactic and interactive methods from human factors science for achieving performance improvement. After this session, participants will be able to: • Explain the use of human factors science, reliability science, and engineering principles in performance improvement • Describe examples from other industries of reliability science, human factors science, and engineering principles being used with measurable success • Build the business case for the use of these concepts in health care, with the IHI safety bundles as an example Krueger, J., MD, Vice President, Medical Director of Quality, UnityPoint Health; Troyer, D., President, Troyer Reliability Consulting C10: Stress and Its Impact on Physicians and Their Families Marco Island Work-related stresses and job dissatisfaction are rapidly growing for physicians. Focusing on the magnitude of the problem and its root causes, this workshop will describe the impact of stress and dissatisfaction on physicians, on their spouses and families, and on patient care and safety. Faculty will share effective approaches and describe the organizational programs available to help participants recognize and address these problems in their own organization. After this session, participants will be able to: • Recognize signs and symptoms of physician stress in organizations and the impact on not only their personal and professional lives but also patient care and safety • Identify successful programs and approaches to managing physician stress that can be implemented in their organization Boehler, R., MD, President and CEO, St. Joseph Hospital C11: The Invaluable Improvement Advisor Grand Ballroom, Salon 4-6 Many organizations seeking to build improvement capacity have found the role of the Improvement Advisor (IA) invaluable to their strategic success. This presentation will discuss the IA role as a leader focused on results and devoted to helping identify, plan, and execute improvement projects throughout the organization. In this session, participants will learn the core skills necessary for an IA and be given tools to help initiate an improvement project. The presenters will demonstrate practical applications of these skills and tools through case stories. After this session, participants will be able to: • Identify the role and core skills of an IA • Assess organizational capacity for leading, planning, and executing improvement projects Ray, D., IA Program Director, Strategic Communications Consulting, LLC; Moen, R., Consultant, Associates in Process Improvement; Posencheg, M., MD, Medical Director, Intensive Care Nursery, University of Pennsylvania Hospital C12: Turning the World Upside Down Sawgrass Even without resources or vested interests, developing countries are continuously innovating and developing new improvement in health care. This session will review successful examples of innovative practices from developing countries that have been used in developed-country settings. Focusing on mental health settings, this session will highlight examples and commentary from around the world. (continued on next page) What workshop are you enjoying? Tweet it using #IHI25Forum 27 CONFERENCE DAY 1 Tuesday DECEMBER 10 After this session, participants will be able to: • Review new mental health programs and practices from developing countries • Identify the principles that could be applied to their area of health care Crisp, N., Former Permanent Secretary in Health, United Kingdom, and Former Chief Executive, National Health Service England; Belkin, G., Associate Professor, NYU School of Medicine, Senior Director for Psychiatry, New York City Health and Hospitals Corporation Improvement Capability C13: Achieving IHI Triple Aim Results for Working-Age Adults: Better Health, Better Care, and Lower Cost for Employed Populations Vinoy Bellin Health, a long-standing IHI Triple Aim prototyping partner, has improved health scores of its employees while reducing health costs and saving over $17 million. Applying the lessons of population health, Bellin has spread these strategies to hundreds of companies in Wisconsin and Michigan, developing strategic partnerships with employers and working towards results together. After this session, participants will be able to: • Explore the drivers of population health to better understand the needs of employed populations • Employ an integrated approach to produce results in each dimension of the IHI Triple Aim • Draw lessons and strategies that can be applied to their own organization Van Straten, R., Vice President, Business Health, Bellin Health; Kerwin, G., President and CEO, Bellin Health C14: At Home: Comprehensive Care of the Frail Elderly Grand Ballroom, Salon 1-2 Advanced-illness programs that deliver care at home to the frail elderly and other high-risk populations can substantially improve outcomes. One such program, delivered by North Shore– LIJ Health System (North Shore–LIJ), provides services to vulnerable and largely disenfranchised patients. This session will discuss the success of this program in substantially reducing hospital visits and improving satisfaction. Participants will also learn how the program has enabled a higher 28 percentage of patients to die at home, through the use of an on-demand clinical model, real-time analytics, community paramedicine, and tight coordination with post–acute care services. After this session, participants will be able to: • Develop, both culturally and operationally, an on-demand clinical model to respond to changes in clinical status • Use real-time analytics to coordinate care and identify patients in need of higher-intensity services • Leverage community paramedicine to assist with patient evaluation and triage during off-hours Jervis, R., MD, Director of Quality, Advanced Illness Management Program, North Shore–LIJ; Poku, A., Clinical Data Analyst, North Shore–LIJ; Smith, K., MD, Vice President and Medical Director for Advanced Illness Management, North Shore–LIJ C15: Breaking the Silent Epidemic of Chronic Obstructive Pulmonary Disease P Crystal Ballroom, Salon E-F Despite being the third-highest cause of both death and hospital readmissions, chronic obstructive pulmonary disease (COPD) is often the silent epidemic in a community. This workshop will tell the story of the Southern Piedmont Beacon Community’s adventure in breaking through the silence surrounding COPD and hardwiring a community for improved outcomes. Participants will hear from a patient— national spokesperson Grace Ann Dorney Koppel—as she shares her story and her own commitment to breaking the silence of the epidemic. Presenters will lead participants through a journey they can re-create in their communities—from screening to spirometry, global initiative for chronic obstructive lung disease (GOLD) guidelines, patient engagement, and pulmonary rehabilitation. After this session, participants will be able to: • Identify the necessary elements of a patient-centered disease management program for COPD patients • Develop a plan for leading change in their community to break the silence of the COPD epidemic • Utilize geo-mapping tools to understand their community’s burden of disease Dorney Koppel, G., Private Practice Attorney and Spokesperson, COPD; Wright, J., MD, Vice President, Innovation, Carolinas Medical Center; Stearns, M., Director of Cardiopulmonary and Pulmonary Rehab Services, Carolinas HealthCare System C16: Measurement for Managing Populations Grand Ballroom, Salon 3 Many organizations and communities struggle with Triple Aim measurement issues. In this session, we will provide frameworks, practical guidance, techniques, resources, and case examples for measuring the IHI Triple Aim. Focusing primarily on measurement of population health, we will draw from our experience at Kaiser Permanente and Health Partners, as well as through the international IHI Triple Aim community. This session will be interactive to allow participants to share successful practices and raise questions. After this session, participants will be able to: • Explain the measurement menu for the IHI Triple Aim • Describe other organizations that have implemented IHI Triple Aim measurement systems • Apply techniques and successful practices for measuring population health Stiefel, M., Senior Director, CMI Center for Population Health, Kaiser Permanente; Knudson, S., Vice President, Health Informatics, HealthPartners C17: Partnering for Improvement: Promoting Child Health Aruba/Bahamas Underutilization of health resources, particularly in underserved populations, places children at significant risk. Home visiting programs support maternal knowledge and mothers’ involvement in their children’s care. This workshop will present results from a federallyfunded project to increase recruitment and retention in home visiting programs in Georgia. We will share the lessons learned from a multi-site quality improvement project involving diverse community-based organizations and program graduates to enhance the engagement of families in evidence-based programs that promote child health. After this session, participants will be able to: • Explain the complexities of collaboration when implementing a multi-site protocol to improve engagement and retention rates of families in programs to promote early childhood health • Utilize strategies for partnering with local providers to provide optimal health and social services for clients and patients Terris, D., Evaluation Unit Lead, Center for Family Research, University of Georgia; Glisson, R., Evaluation Data Coordinator, Center for Family Research, University of Georgia; Grange, C., Applied Research Scientist, University of Georgia Person- and Family-Centered Care C18: Advancing Compassionate, Patient-Centered Care New York/New Orleans Compassionate health care is the recognition and validation of the needs, concerns, and distress of others coupled with actions to offer amelioration during every health-related interaction. Without compassion, care cannot be patient-centered or humane. Participants will engage in appreciative inquiry to share experiences of compassionate care, and they will identify the characteristics of compassionate persons and systems as well as barriers to compassion. Faculty will share findings on these characteristics from a recent national meeting involving 60 health care leaders. 25th Annual National Forum on Quality Improvement in Health Care Participants will identify potential action steps to advance the provision of compassionate health care in their own organizations. After this session, participants will be able to: • Describe the impact of compassionate health care on health care providers, patients, and families • Discuss what a compassionate health care organization looks like • Identify action steps to advance the provision of compassionate health care in their own organizations Lown, B., MD, Medical Director, Schwartz Center for Compassionate Healthcare; Crocker, L., Health Consultant and Writer, Institute for Family-Centered Care C19: Communication, Apology, and Resolution After Error Crystal Ballroom, Salon A-C Despite best efforts, adverse events do occur in health care settings. With the current liability system, litigation is the main pathway for harmed patients to seek compensation. However, this approach not only interferes with the relationship between patient and caregiver and efforts to improve patient safety, but also drives defensive medicine. Another approach is communication, apology, and resolution (CARe). This presentation will share the experience of the Massachusetts Alliance for Communication and Resolution Following Medical Injury, implementing the CARe model. After this session, participants will be able to: • Describe the implementation in two health systems of a disclosure, apology, and offer program to respond to unanticipated clinical outcomes • Explain how to offer patients full disclosure, honest explanations, and an apology with rapid and fair compensation when standards of care are not met Benjamin, E., MD, Senior Vice President and Chief Quality Officer, Baystate Health; Sands, K., MD, Senior Vice President, Health Care Quality, Beth Israel Deaconess Medical Center C20: Is Your Health Care System Conversation-Ready? F Grand Cayman/Puerto Rico The aim of The Conversation Project is to ensure that individuals’ end-of-life wishes are expressed and respected. To this end, our health care system must be prepared to receive an activated public and fully respect end-of-life wishes. This session will outline what it means to be “conversation ready” and present practical strategies from individuals in the field working to meet this ambitious aim. After this session, participants will be able to: • Define what it means to be conversation ready • Identify practical strategies for becoming conversation ready that can be applied in their organization C21: Patient-Centered Segmentation and Designing for Health Chicago/Denver This workshop will present a patient-centered way of segmenting and designing services for a defined population. Participants will learn segmentation of a defined population based on peoples’ goals, aspirations, motivation, and context. After learning to design care specific to the needs and aspirations of patient segments, participants will be able to reduce waste in their organizations, as well as improve uptake of services and build patient engagement in care. This methodology will give participants a deeper understanding of their patient population. After this session, participants will be able to: • Explain the segmentation of a population based on peoples’ needs and aspirations • Describe the concept of persona used in social marketing for segmenting the population • Apply this approach through real examples Whittington, J., MD, Lead Faculty, Triple Aim Initiative, IHI; Vyas, D., Consultant Anesthetist, Calderdale and Huddersfield NHS Trust C22: Learning from Mid Staffs and the Francis Inquiry: How Leaders Can Detect Problems at an Early Stage Grand Ballroom, Salon 12-14 In the past decade, quality of care and patient safety in British hospitals have become the focus of increasing public, professional, political, and regulatory concern. In March 2008, the Healthcare Commission announced that it would investigate quality of care at the Mid Staffs Foundation Trust, and its report in March 2009 documented appalling care at the Trust. This was confirmed by a public inquiry, chaired by Robert Francis, QC, that reported in February 2013. Yet, many warning signs were present —the Trust had a high adjusted death rate, had received several mortality alerts, and had been warned by patients of poor care in 2007. In January 2008, the IHI report commissioned by the English Department of Health, “Achieving the Vision of Excellence in Quality: Recommendations for the English NHS System of Quality Improvement” had made recommendations for improvement in English hospitals, and in 2013 Don Berwick reiterated many of those recommendations in a report to the Prime Minister, David Cameron. In this session, faculty will trace some of the origins of the problems at Mid Staffs, evaluate the advice given by IHI, Francis, and Berwick, and indicate how health care leaders can learn from the Mid Staffs experience and pick up potential problems at an early stage. After this session, participants will be able to: • Describe how the problems at Mid Staffs arose • Identify the early signs of similar problems in other health care systems • Identify one way of developing early warning systems from data analysis, patient and staff feedback, and surveys Jarman, B., PhD, Senior Fellow, Emeritus Professor, Imperial College London; Selberg, J., Executive Vice President and COO, IHI; Berwick, D., MD, President Emeritus and Senior Fellow, IHI C23: Combatting Surgical Site Infections in Hip and Knee Arthroplasty Grand Ballroom, Salon 9-10 Three evidence-based practices have been shown to reduce surgical site infections (SSIs) following hip or knee arthroplasty: Screening patients for Staphylococcus aureus carriage and decolonizing carriers with nasal mupirocin; bathing with chlorhexidine soap or wipes; and using an alcohol-containing preoperative skin disinfectant. Participants will benefit from the work of Project JOINTS (Joining Organizations IN Tackling SSIs), an IHI initiative, and learn how to test and implement these interventions in their facilities. After this session, participants will be able to: • Describe the rationale behind the three evidence-based practices to reduce SSIs • Define the elements of these practices and identify ways to assess current implementations of each practice • Examine how other hospitals have implemented these practices and identify ways to apply them at their own facility Duncan, K., RN, Faculty, IHI; Yokoe, D., MD, Hospital Epidemiologist, Brigham and Women’s Hospital; DiGioia, A., MD, Medical Director and Surgeon, PFCC Innovation Center, University of Pittsburgh Medical Center C24: Creating New Care Models to Ensure Patient Safety Crystal Ballroom, Salon J The program Partnership for Patients was developed by the Center for Medicare and Medicaid Innovation (CMMI) to further advances in patient safety. Premier, a hospital engagement network (HEN) of 450 hospitals in 37 states, will share its approach in developing leadership and culture, creating a reliability culture of failure prevention, and integrating the human factor into process design. Two Premier HEN hospitals will share the low- and high-tech tactics they adopted to achieve a sustainable 40 percent reduction in the incidence of harm to patients. After this session, participants will be able to: • Identify tactics to reduce harm to patients and sustain the reduction at their facility • Develop a reliability culture of failure prevention Barrington, M., RPh, Vice President, Engagement and Delivery, Premier, Inc. McCutcheon Adams, K., LICSW, Director, IHI; Gunther-Murphy, C., Director, IHI What workshop are you enjoying? Tweet it using #IHI25Forum 29 C25: Crew Resource Management Team Training: Improving Outcomes in a Large Dutch Intensive Care Unit C26: Hoshin Kanri for Patient Safety: Success Stories F St. Thomas/West Indies The Cancer Institute at HRVP (State Regional Hospital in Brazil) has developed a strategy deployment for safety using leadership principles that align daily management, safety “huddles,” and alerts to its greater system measures. In a similar vein, the Saskatchewan health care system has made the adoption of a culture of safety its strategic intent by using the Hoshin Kanri method. Presenters will discuss these initiatives in Brazil and Canada and present updates on the latest developments. In aviation, where human factors account for the majority of adverse events, a form of human factors awareness training called Crew Resource Management (CRM) has had a significant impact on air-crew team performance and flight safety. Indeed, CRM has become the cockpit operational standard in spite of a lack of scientific proof that it works. In medicine, scientific evidence on the effects of CRM is still scarce as well. In this workshop, we will present findings from our investigation of the effects of a CRM intervention in an intensive care unit. After this session, participants will be able to: • Recognize the key role of human factors in clinical team performance • Implement the principles of CRM training in their own organization Schellekens, W., MD, Strategic Advisor, The Hague Area, The Netherlands; Haerkens, M., MD, Surgeon and Pilot, Wings of Care; Van der Hoeven, J., Professor in Intensive Care Medicine, Radboud University Nijmegen Medical Center Miami After this session, participants will be able to: • Use both Hoshin Kanri to align organizational goals and outcomes and the standard methods for organizational alignment • Describe the key attributes of a strategic planning and deployment process that embraces continuous improvement principles and puts patients first • Identify ways in which Hoshin Kanri planning can be used to build a shared narrative and facilitate health system transformation Pinto, C., MD, Executive Director, Instituto de Oncologia do Vale, Brazil; Peterson, K., Director, Health System Planning and Policy, Government of Saskatchewan, Ministry of Health, Canada C27: The ACGME Clinical Learning Environment Review (CLER): Pathways to Excellence Crystal Ballroom, Salon P-Q This workshop will provide participants with a brief overview of the CLER program, early experience from the field, and an introduction to the newly released document “CLER Pathways to Excellence: Expectations for an Optimal Clinical Learning Environment to Achieve Safe and High-Quality Patient Care.” Through a series of small group sessions, participants will have the opportunity to explore the six focus areas of patient safety, health care quality (including reducing health care disparities), care transitions, supervision, and duty hours/fatigue management to understand the relationship between resident and fellow engagement. Participants will also identify opportunities to optimize a learning environment while improving patient care. After this session, participants will be able to: • Describe the rationale and goals of the ACGME CLER program • Identify characteristics of an optimal clinical learning environment • Identify opportunities to improve resident engagement in institutional efforts to improve patient safety and health care quality Wagner, R., RN, Vice President, CLER Program, Accreditation Council for Graduate Medical Education (ACGME); Weiss, K., Senior Vice President, Institutional Accreditation, ACGME Visit the IHI Open School Kiosk Enroll in the IHI Open School online courses at the National Forum and bring the spirit of IHI to your home or organization! The Open School allows you and your team to: • Take online courses that fit your schedule • Earn up to 26 CE credits in a cost-effective way • Connect with a like-minded community • Keep up with the latest in leadership and quality improvement Enroll now outside of Conference Information in the Los Angeles room and enter to win a FREE registration to the 2014 National Forum! The winner will be announced at the final keynote session on Wednesday afternoon. 30 25th Annual National Forum on Quality Improvement in Health Care Tuesday SPECIAL EVENTS Complimentary Yoga 6:00 AM – 7:00 AM Key Largo Kaiser Permanente: Imagining Care Anywhere Vendor Presentation PerfectServe Vendor Presentation: How to Improve Outcomes and Efficiency by Simplifying Communication Processes so Clinicians Can Better Coordinate Care 12:45 PM – 1:15 PM Storyboard Reception 4:30 PM – 6:30 PM Exhibit Hall Representatives from organizations with storyboards on display will be available to answer questions, share lessons learned, and network in an informal setting. 10:45 AM – 11:15 AM Palms Foyer Classroom Cypress 1 Effective communication among clinicians is essential to reliable, high-quality care and efficient care coordination. Yet current processes often break down and create delays in treatment. This session describes how PerfectServe works with more than 30,000 physicians and 75 hospitals to remove variability and drive process standardization, which results in improved outcomes and operational efficiency. Conversation Ready Q&A Session DNV Vendor Presentation: Putting Quality Back into Accreditation: How ISO 9001 Drives Process Improvement Open School Q&A Session Presented by: Tyler D. Jones, Director, IT Strategic Services, Kaiser Permanente “Imagining Care Anywhere” demonstrates Kaiser Permanente’s belief that IT is a critical driver in reforming our nation’s health care system and is leading the effort to make health information technologies available at all points of care. This segment provides a demonstration of how the use of connected care, digital health, analytics and big data, and other examples of technology can be used to improve health outcomes. Join the conversation about providing patients with convenient, real-time, personalized care, and transforming health care while improving wellness and affordability with the use of technology. Lunch and Learns 12:40 PM – 1:20 PM Be The Change: Three Things Needed to Achieve Health Equality Crystal Ballroom, Salon H Join a lively discussion about diversity and health equity — one of the key issues in health care today. Social Media 101 Grand Ballroom, Salon 7 Curious about how to use Twitter and other social media sites? Grab your lunch and join Paul Levy, the social media-savvy former hospital CEO, during this informal session. IHI Work-Life Wellness Team Q&A Session 10:45 AM – 11:15 AM IHI booth #301, Exhibit Hall IHI’s Work-Life Wellness team organizes activities for IHI staff to encourage them to embrace and live a healthy lifestyle. Meet members of the team, discuss strategies for keeping your employees well, and join in a fun fitness activity! 2:45 PM – 3:15 PM Palms Foyer Classroom The gradual Integration of ISO 9001 into accreditation enables hospitals that have been accredited by DNV Healthcare to utilize, streamline, and improve their existing quality system in a consistent and understandable manner that fits each hospital uniquely. This session presents practical dos and don’ts gleaned from the integration experience of hospitals nationwide. DebMed Vendor Presentation: Moving Beyond Direct Observation to Electronic Hand Hygiene Monitoring 4:30 PM– 5:00 PM Palms Foyer Classroom View a short presentation on the DebMed® Group Monitoring System, the only electronic hand hygiene system now monitoring at the critical point of patient care with monitored point-of-care dispensers. Register to win a $500 Visa Gift Card! 4:15 PM – 5:00 PM IHI Booth #301, Exhibit Hall Join IHI staff to learn about a new program to help communities and health care organizations encourage and support conversations about preferences for end-of-life care. 5:15 PM – 6:00 PM IHI Booth #301, Exhibit Hall Hear from IHI staff and Chapter Leaders and learn more about the Open School for students and professionals. Sandlot Solutions Vendor Presentation: Leveraging Community HIE to Achieve the IHI Triple Aim 5:15 PM – 5:45 PM Palms Foyer Classroom Proactive patient-centered care coordination relies on seamless, point-of-care access to community-based health records derived from interoperable health information exchange (HIE) and analytic tools that close the gaps in care. A large physician independent practice association leveraged an HIE and analytics platform to achieve lower utilization, cost reductions, improved patient care, and dramatic progress in population health quality. 25th National Forum Celebration 6:30 PM – 10:00 PM Marriott Pool Pavilion Join us by the pool to celebrate 25 years of health care improvement. We’ll be providing food, drinks, and entertainment. This event is free of charge. National Forum 31 SPECIAL interest Breakfasts Network with colleagues and discuss a variety of improvement topics over breakfast! Special Interest Breakfasts (SIBs) are informal group conversations led by an expert facilitator. Wednesday, December 11 • 7:00 AM – 7:45 AM SIB5: How Communities and Health Care Organizations Can Support Conversations about Preferences for End-of-Life Care SIB12: When “Front-Line” means “Proximity to the Enemy”: Does the Language We Use Convey What We Do? Grand Ballroom, Salon 4-6 Facilitator: Tester, C., Strategic Lead for Third Sector Engagement and Partnership, Scottish Government, NHS Scotland Facilitator: McCutcheon Adams, K., LICSW, Director, IHI SIB6: IHI’s Work in Latin America Crystal Ballroom, Salon P-Q Facilitator: Delgado, P., Executive Director, IHI SIB1: IHI’s Passport Program Anaheim Facilitator: Duncan, K., RN, Faculty, IHI SIB2: The AHRQ Health Care Innovations Exchange: Sharing Innovative Solutions and Tools to Improve Quality and Reduce Disparities Crystal Ballroom, Salon K-M SIB14: Why Science is Important for Improvement Facilitator: Ettinger, J., President and CEO, Category One, Inc. Facilitator: Samis, S., Vice President, Programs, CFHI Crystal Ballroom, Salon A-C SIB8: IHI Triple Aim Initiative: High-Risk, High-Cost Populations Crystal Ballroom, Salon N Whittington, J., MD, Lead Faculty, Triple Aim Initiative, IHI SIB3: Facilitating Appropriate Antibiotic Use: Incorporating Interventions into the Work Flow of Hospitalists SIB9: Patient Engagement across the Continuum SIB4: New Designs for Population Health Management: Lessons from the IHI Triple Aim 32 Grand Ballroom, Salon 12-14 Facilitator: Carpenter, D., RN, Innovations Exchange Project Manager, WESTAT Facilitators: Srinivasan, A., MD, Medical Epidemiologist, Center for Disease Control and Prevention; Flanders, S., MD, Professor of Medicine, University of Michigan Hospital and Health System; Jacobsen, D., Director, IHI SIB13: Canadian Foundation for Healthcare Improvement (CFHI): Accelerating Health Care Improvement SIB7: Baldrige-Guided Excellence: It Works New York/New Orleans Chicago/Denver Grand Ballroom, Salon 3 Facilitator: Barber, N., Director of Research, The Health Foundation Grand Ballroom, Salon 9-10 Facilitator: Powell, J., Technical Advisor, Aligning Forces for Quality (AF4Q) Initiative SIB10: Hospital Engagement Network (HEN) Breakfast Crystal Ballroom, Salon G Facilitator: Luther, K., RN, Vice President, IHI SIB11: Joining Forces to Better Manage Population Health Grand Ballroom, Salon 1-2 Grand Ballroom, Salon 7 Facilitators: Feeley, D., Executive Vice President, IHI; Nolan, T., Statistician, Associates in Process Improvement and Senior Fellow, IHI Facilitator: Petry, J., Vice President, Strategic Initiatives, Premier Healthcare Alliance 25th Annual National Forum on Quality Improvement in Health Care CONFERENCE DAY 2 Wednesday DECEMBER 11 keynote three 8:00 AM – 9:00 AM Cypress Ballroom 3 Rapid Fire Workshops 10 minutes, 10 slides In these fast-paced sessions, presenters will have 10 minutes to present 10 slides on the topics listed below. RFD: Innovations in Health Information Technology Grand Ballroom, Salon 4-6 Moderator: Hamnett, P., Vice President of Engineering, IHI Presenters: Galli, B., Industrial Engineer, North Shore – LIJ; Davis, N., Program Director, Clinical Information and Research, Providence Health and Services; Woebbeking, L., Quality Improvement Manager, Grundy County Memorial Hospital; Dolin, J., Founder, Emmi Solutions; Ferrans, R., MD, Physician Executive, Presence Health RFE: Beyond the Walls: IHI Triple Aim Collaborations with Community Leaders Grand Ballroom, Salon 4-6 Moderator: Lewis, N., Director, IHI Nancy Snyderman, MD, Chief Medical Editor, NBC News, interviewing her patient, Lindsay Beck, a two-time cancer survivor Presenters: Kramer, S., Project Manager, Cincinnati Children’s Hospital Medical Center; Gray, R., RN, Head of Early Years Collaborative, Scottish Government; Guy, M., Managing Director, Pueblo Triple Aim Corporation; Bennett, J., Executive Director, The Family Van if the patient is low-risk and thus eligible to be placed on observation status instead of being admitted. Avoiding inpatient stays lowers the risk of infection, improves patient experience, and lowers costs. After this session, participants will be able to: • Develop innovative decision support protocols that impact IHI Triple Aim outcomes • Describe an organization where physician and operational collaboration enables and encourages medical advancement alongside organizational efficiencies Leiterman, G., Vice President, Operations and Hospital Specialty Services, HealthPartners; Moriarty, K., Medical Director, CHF Clinic and Research, HealthPartners Medical Group (D workshops continued on next page) special interest keynotes D1: The Role of Leaders in Building a Culture of Continuous Improvement 9:30 AM – 10:45 AM Cypress Ballroom 3 D/E workshops Storyboard Walkarounds Cypress Ballroom 1 NEW! Take a walking tour of some of the exceptional storyboards submitted this year. Each session will include a moderator and storyboard presenters will stand beside their boards to answer questions. SWD: Process and Outcome Measures from the Partnership for Patients D workshops Shahab Saeed, Vice President & COO, Questar Energy Services E workshops E1: Environmental Sustainability and the IHI Triple Aim 9:30 AM – 10:45 AM 11:15 AM – 12:30 PM 11:15 AM – 12:30 PM Cypress Ballroom 3 All D workshops repeat during E workshops except for special interest keynotes. Moderator: Connors, B., Student, University of Michigan Medical School Presenters: : Lemon, V., RN, Project Lead, Children’s National Medical Center; Baldassarre, D., RN, Oncology Clinical Nurse Specialist, Canter Treatment Centers of America®; Raphael, C., RN, Critical Care Coordinator, NCH Healthcare System; Rhee, C., MD, Assistant Professor, UT Southwestern Medical Center SWE: Leveraging Technology Moderator: Priest, K., Student, Portland State University School of Community Health Presenters: Clark, K., Regional Chief of Optometry, Kaiser Permanente; Sharma, M., Clinical Librarian, London Health Sciences Centre; Preese, L., Quality/Business Manager, Regions Hospital; Lozano, M., Senior Quality Engineer, UT MD Anderson Quality, Cost, and Value D2/E2: Cardiac Protocol: Improving Health, Reducing Costs F Grand Ballroom, Salon 1-2 In the six months since implementation, Regions Hospital’s innovative low-risk heart failure protocol has decreased patient admissions by 35 percent and reduced costs by 80 percent. The protocol utilizes decision support tools built into the electronic health record to help determine Donald Berwick, MD, MPP, President Emeritus and Senior Fellow, IHI Moderating a panel including: Blair Sadler, Senior Fellow, IHI Gary Cohen, Executive Director, Health Care Without Harm Robin Guenther, CEO, Perkins+Will Consulting Practice Jeffrey Thompson, MD, CEO, Gundersen Health System 33 CONFERENCE DAY 2 Wednesday DECEMBER 11 • Develop an action plan to use the lessons from this session to work toward achievement of the IHI Triple Aim for improving primary care delivery Gelmon, S., DrPH, Professor of Public Health, Portland State University; Merrithew, N., Director, PCPCH Program, Oregon Health Authority; Christensen, M., Executive Director, Oregon Health Care Quality Improvement Capability D5/E5: Beyond the CEO: Sustaining ThedaCare’s Culture M New York/New Orleans D3/E3: Lowering Cost, Increasing Value: Starting Points and Approaches for Success Grand Ballroom, Salon 7 This session will provide participants with several frameworks to set up their organization for success with respect to understanding their costs of care and improving value for their patients. Participants will learn basic approaches and ways to apply them to their own setting. After this session, participants will be able to: • Develop a framework for their organization to successfully reduce cost and improve value • Describe uses for value stream mapping in understanding patient flow and related costs • Explain the principles of Time-Driven Activity Based Costing (TDABC) Luther, K., RN, Vice President, IHI; Schilling, L., RN, National Vice President, Healthcare Performance Improvement, Kaiser Permanente; Haas, D., Senior Project Leader, Harvard Business School; Liu, M., MD, Physician, Southern California Permanente Medical Group D4/E4: Primary Care Transformed to Improve Oregon’s Health F Crystal Ballroom, Salon G As part of its strategy to achieve the IHI Triple Aim, Oregon has implemented the Patient-Centered Primary Care Home (PCPCH) program. Rapid rollout to over 350 primary care clinics statewide has been supported by a learning collaborative designed to advance practice transformation. Implementation approaches are being studied to identify early successes and immediate opportunities for improvement. This session will highlight Oregon’s model, implementation strategies, evidence of effectiveness, and lessons learned to improve health and health care while lowering costs. After this session, participants will be able to: • Describe the facilitators of implementation of the PCPCH, as well as the barriers to implementation • Identify opportunities for replication and application of lessons from the Oregon PCPCH experience for state governments, broad-scale initiatives, and clinics in other organizations and regions 34 When the CEO retires or leaves, an organization changes. The culture of improvement can be destroyed overnight by the new leader. Lasting change requires that organizations hardwire improvement thinking into succession candidates. It also requires board commitment to choosing internal candidates with the characteristics required to accelerate the improvement journey. In this workshop, ThedaCare’s former CEO, John Toussaint, and present CEO, Dean Gruner, will describe the process of sustaining an improvement culture that outlives the tenure of any one CEO. After this session, participants will be able to: • Identify the standard work for succession planning that senior management and boards use to choose leaders • Implement a management system that hardwires improvement skills into all succession candidates Toussaint, J., MD, CEO, ThedaCare Center for Healthcare Value; Gruner, D., MD, President and CEO, ThedaCare D6/E6: Achieving Results at Scale: Building Capability and Capacity for Improvement Across a Region Sawgrass As we increasingly seek to improve the health of populations at the regional level, how do we build a workforce that has the capacity to make effective change and is capable of understanding and applying improvement and innovation methodologies? In this workshop, participants will learn from existing efforts to improve health care at a regional or country level to build capacity and capability to achieve improved patient outcomes. After this session, participants will be able to: • Identify approaches to developing capacity and capability for improvement and innovation at a regional level • Derive strategies for motivating and creating a high-performing workforce for innovation and improvement Mate, K., MD, Vice President, IHI; Richmond, M., Chief of Clinical Affairs, Hamad Medical Corporation; Ruelas, E., Senior Fellow, IHI; Davis, H., General Manager, Ko Awatea, Counties Manukau District Health Board D7/E7: Closing the Knowing-Doing Gap Crystal Ballroom, Salon D Six frogs are sitting on a lily pad, and one decides to jump. How many frogs are left on the lily pad? Six—because “deciding” and “jumping” are different verbs. Is your leadership team made up of well-intentioned frogs or jumping frogs? Is your leadership team aligned in its leadership mindset, goals, and resources? Does your organization hold people accountable for executing well? In this workshop, you will learn evidence-based leadership practices that will help you jump over the quality chasm. After this session, participants will be able to: • Identify the barriers to improvement that are keeping their leadership team on the lily pad, as well as the opportunities for improvement being missed • Implement three evidence-based practices that will improve their ability to execute system goals Deao, C., Senior Leader, Studer Group D8/E8: Emergency Department Clinical Information Manager: The Scribe Program Grand Cayman/Puerto Rico The mission of the Scribe Program is to facilitate and to expedite emergency department patient flow by allowing providers to spend more time on direct patient care and education while concurrently producing more thorough and higher-quality documentation. Among the topics discussed in this workshop will be operational improvement, patient satisfaction, physician satisfaction, education, and financial performance. After this session, participants will be able to: • Educate health systems, academic medical centers, and community hospitals about the benefits and challenges of implementing a clinical information manager-scribe program • Create a model for a homegrown clinical information manager and scribe program Raj, P., Vice President of Clinical Informatics, Emergent Medical Associates; Ferrigno, R., Chairman, Department of Emergency Medicine, Bridgeport Hospital D9/E9: Measuring Improvement F Crystal Ballroom, Salon H How do we know that a change is an improvement? Many teams struggle to select an effective set of measures to track improvement, without missing important trends or getting lost in a host of irrelevant data. This session will present a structured approach to answering the “measurement question,” beginning with an explicit theory of improvement, priorities for interventions, and identification of key outcome and process indicators. We will also review the relationship between outcome measures, project measures, and Plan-Do-Study-Act (PDSA) measures. 25th Annual National Forum on Quality Improvement in Health Care After this session, participants will be able to: • Differentiate measurement for improvement from measurement for research • Use a driver diagram to identify key interventions and associated measures • Discuss the relationship between process and outcome measures and identify critical measures needed to track improvement Scoville, R., PhD, Improvement Advisor and Consultant, IHI D10/E10: Principles and Pitfalls for Running Breakthrough Series Collaboratives Grand Ballroom, Salon 9-10 Breakthrough Series (BTS) collaboratives can be a powerful tool for spreading improvements in organizations, communities, and regions, but only if established design principles are used and common pitfalls are avoided. Using a wide range of examples, this session will cover everything from selecting a topic, building change packages, measurement systems, engaging teams, and running robust learning sessions and action periods. Participants will gain a deeper understanding of the BTS method, including what to consider in making adaptations to the traditional model and how to diagnose and address common issues and challenges. After this session, participants will be able to: • Apply established design principles for successful BTS collaboratives • Diagnose and address the common issues and challenges that arise using the BTS method Schall, M., Senior Director, IHI; Murray, S., Improvement Advisor, CT Concepts; McCutcheon Adams, K., LICSW, Director, IHI D11/E11: Teams and Technology: Transforming Care as We Know It F Grand Ballroom, Salon 12-14 This session will look at the way we develop care teams and leverage health information technology to transform the way we deliver care. A group of multidisciplinary leaders at Kaiser Permanente will discuss how care teams have become better able to use process improvement and technology while including patients in care improvement projects. Through interactive exercises, participants will translate key principles and learnings to various organizational structures and care settings. After this session, participants will be able to: • Identify how to develop effective care teams that can leverage advanced health information technology • Explain how teams can use health information technology to accelerate their ability to transform care and become skilled in process improvement • Apply core principles and learnings of technology-supported care teams in their own organization Chow, M., PhD, RN, Vice President, National Patient Care Services, Kaiser Permanente; Fredriks, D., PharmD, Director of Clinical Pharmacy Services, Kaiser Permanente D12/E12: Why So Slow? Spreading Success for Leaders D14/E14: Emergency Care of Frail Older People Crystal Ballroom, Salon N Crystal Ballroom, Salon P-Q Why is it difficult to spread the excellence achieved in one area of a system throughout the system? The keys to doing so lie in unlocking delays to adoption and in reliable implementation at scale. This session will provide participants with an approach and a toolkit for spread. Participants will learn by doing in an interactive way and come away with how-to knowledge and practice on the key components for spread. Faculty from three high-performing systems from around the world will lead and share approaches and examples. Increasing numbers of older people are seeking emergency care in hospitals and other settings across the world. This has resulted in negative outcomes for older people in emergency departments (EDs) and following hospital admissions. It is time to rethink the paradigms for health and social care for the future from the perspectives of older people, their careers, and society. Participants in this workshop will learn what to consider when trying to understand the needs of frail older people in order to offer the most satisfying, appropriate, timely, and effective responses. After this session, participants will be able to: • Develop an approach to get the best care in their system reliably spread throughout it • Test (and later teach) this approach to spreading excellence Henriks, G., Chief Executive of Learning and Innovation, The County Council of Jönköping; Compton-Phillips, A., MD, Associate Executive Director, Quality, Kaiser Permanente; Longmate, A., MB ChB, National Clinical Lead for Patient Safety, Scottish Government Triple Aim for Populations D13/E13: Delivering Value Through Emergency Department–Medical Home Coordination Crystal Ballroom, Salon K-M Saint Francis Care and Dartmouth-Hitchcock Medical Center launched an initiative to improve health through a value-oriented approach that coordinates care across the emergency medicine–primary care continuum at these two very different sites. The teams have worked together to achieve a consistent set of aims and demonstrate that one size does not fit all when implementing innovation at the local level. In this workshop, these teams will share insights and tools for better understanding patient utilization and improving coordination. After this session, participants will be able to: • Identify approaches to understanding patient patterns and preferences in their emergency department (ED) • Utilize an awareness of the tools and technology that help reduce low-value ED encounters and improve care coordination • Recognize the benefit of a patient-centered ED registry in delivering value to high users Makoul, G., PhD, Chief Academic Officer and Senior Vice President for Innovation, Saint Francis Health System; Curtis, K., MD, Program Director, Emergency Medicine Residency, Dartmouth-Hitchcock Medical Center After this session, participants will be able to: • Identify frail older people in the ED • Implement quality care for older people in EDs Banerjee, J., Consultant in Emergency Medicine, University Hospitals of Leicester NHS Trust; Carpenter, C., MD, Assistant Professor, Emergency Medicine, Washington University in St. Louis D15/E15: Successes in the Journey to Improve Health Equity Chicago/Denver In order to provide more culturally-responsive care to an increasingly diverse patient population, new partnerships across the care continuum are necessary. At Kaiser Permanente, attempts to address the “total health” of the patient have benefited from the creation of interdisciplinary care teams with members ranging from nursing to operations, service, and risk. Promising best practices with multiple cross-site pilots have also been demonstrated in partnerships with barbershops, health navigators, and community health centers. Participants in this workshop will learn how to leverage the best practices developed across these multiple sites to improve health equity. After this session, participants will be able to: • Identify culturally appropriate tools that address the mental, social, and behavioral health of the individual while also improving population care • Implement strategies to engage interdisciplinary care teams within the community to improve patient health outcomes Wong, W., MD, Clinical Director, Kaiser Permanente; Gould, B., RN, Senior Director, Quality, Hospital Oversight, Kaiser Permanente D16/E16: Transitioning into a New Model of Care: One Year Post-IHI National Forum Marco Island One year after incorporating the changes proposed at the 2012 IHI National Forum, the model of care at Ochsner Clinic had achieved substantial gains in service (resulting in a 96 percent rate of patient satisfaction) and access (removing system and self-imposed barriers related to providers’ schedules to more frequently (continued on next page) What workshop are you enjoying? Tweet it using #IHI25Forum 35 CONFERENCE DAY 2 Wednesday DECEMBER 11 keynote four what they need—no more and no less. After this session, participants will be able to: • Describe the six steps of shadowing as a standardized, simple mechanism to improve care experiences and outcomes, remove waste, and decrease costs • Use shadowing to define exactly what patients want and need while engaging staff in the redesign of care delivery • Achieve the emotional connection with patients that can drive change efforts DiGioia, A., MD, Medical Director and Surgeon, PFCC Innovation Center, University of Pittsburgh Medical Center (UPMC); Schraeder, L., Organizational Development Consultant, UPMC 1:30 PM – 2:30 PM D18/E18: Storytelling: The Why and the How P Cypress Ballroom 3 Grand Ballroom, Salon 3 Stories have the power to engage hearts and minds and to bring diverse interests together around common goals. Sharing their experiences of collecting and sharing stories in a variety of settings, faculty in this workshop will discuss how to tell a story and when sharing is most effective. Participants will learn about ethnography, social media, and ways to harness patient and family stories as well as those of staff and clinicians. Donald Berwick, MD, MPP, President Emeritus and Senior Fellow, IHI provide same-day access). These gains have led to an increase in visits while lowering cost, while also increasing capitation allocation. In this session, you’ll learn what Ochsner took home after last year’s National Forum, and what exactly they did to see such great results only one year later. After this session, participants will be able to: • Articulate the challenges moving from a volume-based to a value-based practice • Consider changes that worked for Ochsner that might also work in their own setting Genzer, K., Chief Operating Officer, Ochsner Clinic; Hart, R., MD, Regional Medical Director, Ochsner Clinic Person- and Family-Centered Care D17/E17: Go Shadow: See Patients’ Wants and Needs While Lowering Costs S Grand Ballroom, Salon 8 Shadowing patients and families is a powerful mechanism for identifying opportunities to transform patients’ care experiences as well as clinical and operational outcomes while reducing waste and cost. Shadowing creates co-design partnerships with patients and families and harvests the power of staff engagement in care redesign. This session will teach participants how to use shadowing to provide patients with exactly 36 After this session, participants will be able to: • Describe the role of stories in accelerating change and improvement • Develop a powerful case for integrating stories into their setting • Describe the most effective story formats for different audiences Hayward, M., Lead, Patient and Family Engagement, IHI; Haskell, H., President, Mothers Against Medical Error; Chase, A., Senior Vice President, Medicare Clinical Operations and Population Care, Kaiser Permanente D19/E19: Student- and ResidentDriven Patient Safety Programs F S Vinoy Medical students and residents from around the country who attend the Telluride Educational Roundtable have the opportunity to learn about patient safety and medical quality and collaborate on projects under development at their home institutions. This workshop will feature student and resident participants from the last eight years of the program discussing projects they initiated and will provide an opportunity for participants to discuss how to design similar programs at their own organizations. After this session, participants will be able to: • Articulate examples of student- and resident-driven medical quality initiatives • Discuss strategies for implementing collaborative models in undergraduate and graduate medical education settings Mayer, D., MD, Corporate Vice President, Quality and Safety, MedStar Health; Kantrowitz, M., DO, Physician, Maimonides Medical Center; Levy, P., Author; Hatoun, J., Resident, Boston Medical Center; Morrison, K., Medical Student, University of Missouri at Columbia; Grandhi, R., Medical Student, University of Cincinnati D20/E20: Caring for Maria: Improving Things That Matter in Ambulance Service Anaheim Ambulances treat and transport an estimated 16 million patients to emergency departments annually. The 2006 Institute of Medicine report “EMS at the Crossroads” recommended developing evidence-based care and effective measurement for emergency medical service (EMS). In this workshop, participants will learn how American Medical Response, the largest ambulance provider in North America, is leading a national improvement collaborative to reduce harm and improve care outcomes while sharing its results with the industry. After this session, participants will be able to: • Discuss the development of measurement and change ideas in an innovation space • Recognize the elements of a sustainable national improvement collaborative system • Identify the individual and organizational challenges of executing improvement in the EMS setting Williams, D., PhD, Improvement Advisor, TrueSimple Consulting; Bourn, S., PhD, Vice President of Clinical Practices and Research, American Medical Response; Taigman, M., General Manager, American Medical Response; White, L., National Director of Resuscitation and Accountable Care, American Medical Response D21/E21: Code Red: A Team-Based Approach to Surgical Fire Prevention Miami Surgical fires continue to be a preventable and serious source of patient injury in the United States. The ECRI Institute estimates that as many as 650 surgical fires occur annually, often resulting in second- and third-degree burns or, in the case of airway fires, more serious injuries or death. Most, but not all, of these patient injuries occur in the setting of surgery, where a coordinated team-based effort is required to eliminate this hazard. This workshop will focus on the scope of the problem and offer a multidisciplinary strategy to address it. After this session, participants will be able to: • Identify scenarios of high risk of fire injury • Implement team strategies in complex surgical environments Hannenberg, A., Board Chair, Council on Surgical and Perioperative Safety; Constantine, R., PhD, Assistant Director of Mid-Level Practitioners, Saint Francis Hospital; Dagi, T., MD, Director and Chief Medical Officer, Prismic Pharmaceuticals D22/E22: How Safe Are You? Harm Measures Panel Discussion M Grand Ballroom, Salon 11 There is much debate as to how to determine how safe our systems are. In this session, a panel of experts will describe different harm 25th Annual National Forum on Quality Improvement in Health Care measurements and share with participants, in an interactive discussion, ways to apply them in their own institutions. D25/E25: Scotland’s Quality Journey After this session, participants will be able to: • Describe the different approaches to measuring harm in systems • Discuss the advantages and disadvantages of these harm measurements Six years ago, the political leaders, the clinicians, and the managers of Scotland’s health care system set out on an ambitious journey to reduce mortality and harm. Success in that effort led to a more ambitious and broader approach to health care quality that goes beyond safety and, more recently, even beyond health care. This session will describe what Scotland did, by what method, and the lessons learned. Participants will have an opportunity for interactive learning, including applications to their own settings. Federico, F., RPh, Executive Director, Strategic Partners, IHI D23/E23: Measuring Harm in the UK National Health Service Aruba/Bahamas In 2011 the National Health Service (NHS) England embarked on an unprecedented journey to devoting one day per month to measuring harm proactively on all NHS patients. The measurement instrument, known as the NHS Safety Thermometer, has now been used on over 2 million NHS patients. In this session, presenters will share some of the data from this data collection system, as well as lessons learned from establishing this system for measuring harm. After this session, participants will be able to: • Identify the challenges of measuring safety at scale • Describe the design principles of the safety measurement system known as the NHS Safety Thermometer • Use the lessons learned from the implementation of this large-scale change initiative Power, M., Director, Salford Royal Hospital Foundation NHS Trust; Warren, A., Project Manager, Department of Health, United Kingdom D24/E24: Reliable Application of Sepsis Bundle Elements Crystal Ballroom, Salon J The North Shore–Long Island Jewish Health System (North Shore–LIJ) has partnered with IHI to conduct a multi-hospital collaborative focused on increasing the reliability of sepsis, severe sepsis, and septic shock bundle elements. Focused on the emergency department and the medical/surgical floors, the work has resulted in significant improvement in process measures and clinical outcomes. In this session, faculty will discuss the methodology, results, and hurdles, along with the methods that were successful in this work. After this session, participants will be able to: • Identify barriers to improving front-line implementation of key elements of the sepsis bundle • Develop new processes that decrease delays in the care of patients with severe sepsis and shock D’Angelo, J., MD, Senior Vice President, Emergency Services, North Shore–LIJ; Doerfler, M., MD, Senior Vice President, Clinical Strategy and Development/ Associate CMO, North Shore–LIJ; Parmentier, D., RN, Director, Critical Care, Telemetry, and Emergency, Glen Cove Hospital; Jacobsen, D., Director, IHI Harbor Beach After this session, participants will be able to: • Assess the impact of Scotland’s national quality improvement change program • Apply the lessons learned from Scotland to their own work to achieve change at scale Leitch, J., Clinical Director, Quality Unit, Scottish Government Health Department; Feeley, D., Executive Vice President, IHI D26/E26: Using Evidence to Prevent Falls: Skilled Nursing Crystal Ballroom, Salon E-F The three skilled nursing facilities of the North Shore–LIJ Health System (North Shore–LIJ) have reduced patient falls with injuries to far below state and national benchmarks by using an interdisciplinary team approach and engaging patients/residents and families in risk reduction strategies. This workshop will present some of the evidence-based practices adopted by North Shore–LIJ, including strict monitoring of high-risk patients/residents, shift-to-shift walking rounds, physical therapist consults, and reductions in psychotropic medications. After this session, participants will be able to: • Identify five evidence-based practices that were adopted at North Shore–LIJ to prevent patient/resident falls • Describe how patients and families are engaged in strategies for reducing the risk of falls Geraghty, B., RN, Associate Executive Director, Patient Care Services, Stern Center for Rehabilitation; Grogan, M., RN, Associate Executive Director, Patient Care Services, Orzac Center for Rehabilitation, Healy, M., RN, Chief Nursing Officer, Broadlawn Manor Nursing and Rehabilitation Center D27/E27: Building an Integrated Outpatient Safety Net Program Crystal Ballroom, Salon A-C This workshop will discuss the right way to build a centralized surveillance system—including leveraging data, electronic tools, and a modest staff to address a variety of clinical situations where ambulatory patient safety is at risk. After this session, participants will be able to: • Identify where opportunities are to systematically address patient safety issues outside of the traditional inpatient setting • Target specific patient populations within two primary areas of out patient safety: Medication safety/ diagnosis detection and follow-up care • Develop an outpatient safety program by creating a series of centralized safety nets to catch errors Kanter, M., MD, Medical Director, Quality and Clinical Analysis, Kaiser Permanente Regional Quality and Risk Management; Smith, A., Regional Safety Net Consultant, Southern California Permanente Medical Group Wednesday SPECIAL EVENTS Simpler Healthcare Vendor Presentation: Lean Leadership Immersion for Health Care 10:45 AM – 11:15 AM • Palms Foyer Classroom You may know Lean tools are only part of the solution to transforming your entire workplace. What do you know about the pivotal role leaders play in getting beyond use of the tools and changing the behavior of the entire organization? What is the essential short list of things leaders do to make the difference in capturing the hearts and minds of all employees? Come find out in this 30 minute session led by Simpler Healthcare. Institute for Enterprise Excellence (IEX) Vendor Presentation: Lean Health Care, Enterprise Excellence, and The Shingo Model 12:45 PM – 1:15 PM • Palms Foyer Classroom IEX—founded by Jacob Raymer, an HVN Board Member and former Executive Director of Education for the Shingo Prize— provides management systems, research, learning resources, and thought leadership to the health care industry. This session will describe how systems, principles, and cultural enablers are used to identify strategic gaps and develop strategic/ operational roadmaps. “The knowledge gained from this [approach] is truly a game changer”— Cleveland Clinic. Join us to hear more. What workshop are you enjoying? Tweet it using #IHI25Forum 37 SHUTTLE Map Conference Headquarters 38 25th Annual National Forum on Quality Improvement in Health Care cfhi-fcass.ca Education for today’s healthcare leader Explore CFHI’s distance learning and face-to-face improvement workshops. CFHI’s programs build your skills to help you improve the way healthcare is organized, managed and delivered. Enrollment begins December 2013. Program begins February 2014! To view our catalogue or for more information, visit cfhi-fcass.ca Contact: Linda Piazza Senior Director, Education and Training [email protected] | 613.728.2328 ext 347 Please scan here to be added to the mailing list. The Canadian Foundation for Healthcare Improvement is a not-for-profit organization funded through an agreement with the Government of Canada. conference Map Patient and Family Advisor booth This way to the North Tower D N 11 Bookstore 3 Registration Changes & Badge Edits First Aid Conference Information 40 25th Annual National Forum on Quality Improvement in Health Care conference Map Exhibit Hall & Wellness Pavilion Storyboards & Luggage Storage Keynote Room Entrance Registration Presenter Prep Room & Lounge Shuttles Shuttle Service To: Gaylord Palms Resort & Convention Center Courtyard Orlando Lake Buena Vista in the Marriot Village Springhill Suites Orlando by Marriott Caribe Royale Buena Vista Suites More details in Shuttle Map on page 38. To Access Complimentary Wireless Internet: 1. Select “view available wireless networks” and connect to the “Marriott_CONF “ 2. Open a new web browser and type “ihi.org” into the address bar. You will be redirected to the Marriott/ VreeHealth webpage. 3. Enter “IHI25FORUM” as the meeting passcode and click “submit” (passcode is case sensitive.) 41 W H AT I F T H E R I G H T I N F O R M AT I O N F O U N D YO U ? W I T H T H E D I G I TA L E N V E L O P E , I T C A N . Sandlot Solutions understands exactly what information you need and how to deliver it. Our fourth-generation health information exchange + analytics combines clinical knowledge and claims data with business intelligence to help you manage risk and demonstrate value. Through our “digital envelope,” you receive compliance and evidencebased care alerts at the point of care, within your workflow. You get high-level visibility to monitor quality measurements, patient outcomes and population trends. And, of course, the digital envelope works with our care manager platform or yours. All of this through the cloud. Find us, and we’ll make sure the right information finds you. Call 800-370-1393 or visit sandlotsolutions.com for more information. 42 25th Annual National Forum on Quality Improvement in Health Care general conference Information Shuttle Service to Other Hotels National Forum Bookstore Guests During the conference, IHI will provide National Forum participants with complimentary shuttle transportation to the Marriott World Center. Shuttles will run every 10 to 20 minutes from the following locations: • Gaylord Palms Resort and Convention Center • Courtyard Marriott Lake Buena Vista Hotel • Marriott Village Springhill Suites • Caribe Royale • Buena Vista Suites Located in the Crystal Foyer, the National Forum Bookstore features books written, edited, or recommended by our world-renowned faculty. It will be open during the following times: We are excited that family and friends are accompanying many of you. We regret that hotel space can accommodate only registered participants at the keynote presentations, general sessions, and meal functions. Your guests are welcome to join you at the National Forum receptions. Please see IHI staff at the registration desk for a guest ribbon and name badge. See page 38 for shuttle map. Shuttle Operating Hours Sunday, December 8, 6:30 AM – 10:00 PM Monday, December 9, 6:30 AM – 10:00 PM Tuesday, December 10, 6:30 AM – 10:30 PM Wednesday, December 11, 6:00 AM – 4:00 PM IHI will also provide complimentary shuttle service from the Marriott World Center to Orlando International Airport on the last day of the General Conference, Wednesday, December 11, from 12:00 PM to 4:00 PM. Exhibit Hall Hours The 2013 Exhibit Hall includes snack stations, a new wellness pavilion, and over 130 exhibitors. The exhibit hall will be open in the Palms Ballroom during the following times: Monday, December 9 3:30 PM – 6:30 PM Welcome Reception 4:30 PM – 6:30 PM Tuesday, December 10 9:30 AM – 10:30 AM (By appointment only) 10:30 AM – 1:30 PM 4:15 PM – 6:30 PM Storyboard Reception 4:30 PM – 6:30 PM Wednesday, December 11 Monday, December 9, 7:30 AM – 6:00 PM Tuesday, December 10, 7:30 AM – 6:30 PM Wednesday, December 11, 7:30 AM – 1:30 PM Many of the National Forum Bookstore authors will have scheduled a time for book signings. These events will be advertised around the conference center and on Twitter using #IHI25Forum. Business Center Located next to the Palms registration desk in the Crystal Foyer, the full-service business center offers professional printing services as well as shipping, receiving, copying, and faxing. Business Center hours are: Monday – Friday, 7:00 AM – 6:30 PM Saturday – Sunday, 8:00 AM – 4:00 PM Health Center Message Board/Job Postings Job postings and messages can be posted on the corkboard located next to the registration desk located in the Palms Foyer. Messages and Faxes If you are staying at the Marriott World Center, your telephone messages will go directly to your room. If a caller identifies you as being with the National Forum, urgent messages will be posted on the message board located next to the National Forum registration desk near the Convention Center entrance. Marriott World Center contact numbers are: Phone: 407-239-6411 The health center is a separate building on the Marriott World Center property, located beyond the pool. It is a fully equipped athletic facility with indoor and outdoor pools, a full spa, whirlpools, and saunas. The health center is open 24 hours, with an attendant from 6:00 AM until 10:00 PM. Use of the fitness center is complimentary for overnight guests. Guest Fax: 407-239-6164 Checkout Unattended Belongings Checkout from at the Marriot World Center is at 11:00 AM. If you are staying at the Marriott, please see the hotel bell staff about storing any luggage after checkout. On the last day of the conference, IHI Blue Shirts can help you check your luggage in Cypress 1. Please do not leave any personal belongings unattended in meeting rooms. IHI is not responsible for lost or stolen items. Emergencies If for any reason there is an emergency during the National Forum, dial 55555 on any hotel phone to be connected to security. IHI Blue Shirt and Marriott World Center staff are also available to assist. Name Badges Please wear your name badge throughout the National Forum and carry your list of registered sessions with you. This is your ticket into the conference and all sessions. Please Note IHI will have video cameras and photographers at the National Forum. We may capture your image for use on IHI TV at the National Forum, on the IHI website, or in other IHI materials. 10:30 AM – 1:30 PM 1:00 PM: Forum Fortune Drawing at IHI Booth #301 43 general conference Information Green Initiatives IHI continues to make a concerted effort to reduce the environmental impact of the National Forum and all IHI events. In year seven of this effort, you may notice the following changes: • All presentations made available to IHI by presenters before the conference will be available to participants on ihi.org. Participants need to log in and then click on “My IHI” at the top of the screen, navigate to “My Enrollments and Certificates,” and find the link under “25th Annual National Forum on Quality Improvement in Health Care” for “Materials/Handouts.” Paper handouts will not be provided for any session. If you would like paper handouts, please print your materials before your arrival or visit printing stations in the Los Angeles meeting room. • Meeting materials are also available in the IHI Onsite app. Search the App store or Android market for IHI Onsite. • The entire meeting space will have high-speed wireless Internet access. We encourage participants to bring their laptops to their sessions to take notes and view presentations. Meeting rooms will be set up with work tables when session capacity allows. • IHI works with the conference center to eliminate waste from paper and plastic food packaging and to use local and organic food products whenever possible. • Food not consumed by attendees will be donated to a local food bank. • Exhibit Hall giveaways and other meeting supplies that are not distributed will be donated to local elementary and middle schools. • Recycling containers will be made available for recyclable meeting materials and catering items. • Transportation to the airport at the close of the conference will be available to attendees in an effort to offset our carbon footprint by ride-sharing. We encourage you to stop by the registration desk to give us your feedback on how we can continue to reduce the impact of the IHI National Forum on the environment. 44 25th Annual National Forum on Quality Improvement in Health Care FORUM Fortune You’ve Got to Play to Win Visit each of these Forum Fortune Booth Sponsors, get their stamp or signature, and return your completed card to the IHI booth by 11:30 AM on Wednesday, December 11. Drawing will be on Wednesday, December 11 at 1:00 PM at the IHI Booth (#301). You must be present to win, and exhibitors are ineligible. Prizes include Apple gift cards, a Wii Fit, a Kindle Fire, Visa Gift cards, an iPad, and a free registration to the 2014 National Forum, among others. You need stamps from each of these sponsors. Ninon Koden Booth #107 Amphion Medical Solutions Booth #113 Navex Global Booth #213 MCN Healthcare Booth #316 DNV Healthcare Booth #513 Dialog Medical Booth #706 Dimensional Insight Booth #801 Krames Staywell Booth #815 Columbia Heartsource Booth #817 Lightshed Healthcare Technologies Booth #914 National Database of Nursing Quality Indicators Booth #1002 MCG Booth #1012 Medkinetics Booth #1001 E E R F E C A SP Healthstream Booth #1006 Sandlot Solutions Booth #1013 Conifer Health Solutions Booth #1200 CHG Hospital Beds Booth #1201 VigiLanz Corporation Booth #1206 Joint Commission Resources Booth #1400 Care Team Connect Booth #1418 Acesis Booth #1424 Name: Organization: Email: 45 EXHIBIT HALL Floor Plan STORYBOARD ENTRANCE IHI 46 25th Annual National Forum on Quality Improvement in Health Care CONTINUING Education Continuing Education Attendees of the 25th Annual National Forum on Quality Improvement in Health Care will learn how to: • Recognize habits that support quality health care and apply the basic principles for improving them • Define ways to reduce suffering and improve health • Develop an understanding of how to transform an organization Identify elements for creating a culture of change that will lead to continuous improvement In support of improving patient care, the Institute for Healthcare Improvement is accredited by the American Nurses Credentialing Center (ANCC), the Accreditation Council for Pharmacy Education (ACPE), and the Accreditation Council for Continuing Medical Education (ACCME), to provide continuing education for the health care team. The National Forum carries a maximum of 19.25 credits for physicians, nurses, and pharmacists. The Institute for Healthcare Improvement designates this live activity for a maximum of 19.25 AMA PRA Category 1 Credit(s)™. Physicians should claim only the credit commensurate with the extent of their participation in the activity. This program is approved by the National Association of Social Workers (Approval #886367066-2477) for 19 Social Work continuing education contact hours. All National Forum Learning Labs, Minicourses, and General Conference sessions offer ANCC, ACPE, ACCME, and CPHQ credits except for the following sessions, which offer ANCC, ACCME, and CPHQ credits. Please note the exceptions for ACPE below: Sessions that do not offer pharmacy contact hours: L11, L20, L25, M14, M16, A4/B4, A7/B7, A14/B14, A25/B25, C7, C8, C10, C12, C27, D4/E4, D6/E6, D20/E20, D21/E21 Sessions that offer social worker credits: L3, L8, L11, L19, L22, L23, L24, L26, M6, M10, M12, M15, M17, M18, M19, M20, M22, M23, A2/B2, A8/B8, A10/B10, A16/B16, A18/B18, A19/B19, A20/B20, A21/B21, A22/B22, A23/B23, A25/B25, B1, C1, C2, C6, C12, C13, C14, C15, C17, C18, C19, C20, D4/E4, D13/E13, D14/E14, D15/E15, D17/E17, D18/E18, D27/E27, FE3, FE6 How to receive a certificate of credit: To be eligible for a continuing education certificate, attendees must complete the online evaluation within 30 days of the continuing education activity. If circumstances prevent you from completing the survey by the specified deadline, please email [email protected] before this time period expires. After this time period, you will be unable to receive a continuing education certificate. 1. Go to ihi.org/certificatecenter. (If you are not logged into the website, you will be redirected to the log-in screen. Once you are logged in, you will be redirected back to the Certificate Center.) 2. Click on the “25th Annual National Forum” link that appears under the “Create Certificate” header. 3. Select the type of credits you wish to receive from the drop-down list and then click “Submit.” 4. Review your enrollment and click “Continue.” 5. Take the surveys associated with each of the sessions you attended and for which you wish to receive credits by selecting “Take Survey Now” next to the session. 6. Once you have completed all of the associated surveys, “Generate Certificate” will be activated. Click on this button to generate a PDF file of your certificate that you can print or save to your computer. 47 STORYBOARDs Storyboard Reception Tuesday, December 10, 4:30 PM – 6:30 PM, Palms Ballroom During this reception, presenters will be standing by their boards to answer questions. Quality, Cost, and Value QC1: A Flow Transformation Fire Starter: Reducing Time to Inpatient Bed Cambridge Memorial Hospital (Ontario) Nisha Walibhai, RN [email protected] QC2: A RARE Approach to Reducing Readmissions Institute For Clinical Systems Improvement Joann Foreman, RN [email protected] QC3: A Spine Model with Demonstrable Cost Savings HealthPartners Bret Haake, MD [email protected] QC4: A Unique Approach to Problem-Solving for Health Care Guthrie Clinic Vickie Kamataris, RN [email protected] QC5: Analytical Framework for Improving Organizational Quality Stetson University Joseph M. Woodside [email protected] QC6: Applying a Tourniquet to Blood Utilization Franciscan Alliance Beth Grbavac, RN [email protected] QC7: Applying Lean Acrross the Continuum of Care University Health Network Sylvie Robinson [email protected] QC8: Applying Lean Concepts to Health Care Processes University of Texas, MD Anderson Cancer Center Pheba Philip [email protected] QC9: Applying Tracer Methodology to Reduce Cardiac Surgery Readmissions at Hospital of the University of Pennsylvania UPHS Jo Anne Fante-Gallagher, RN [email protected] QC10: Benefits From Quality Improvement to Increase Efficacy of Rounding Nationwide Children’s Hospital Jeff Lewis, RN [email protected] QC11: Benefits of Managing Low-Density Lipoprotein Particles: A Cost-Effectiveness Analysis S2 Statistical Soultions, Inc. Peter Mallow, PhD [email protected] 48 QC12: Bone Remodeling and Health Care Reform Kapiolani Medical Center for Women and Children Byron Izuka, MD [email protected] QC13: Bridging the Gap Between Pharmacy and Nursing: The Value of a Decentralized Pharmacy Technician University of Connecticut Amanda Miller [email protected] QC14: Butterworth Hospital Inpatient Pharmacy: Improving Inventory Management Throught LEAN Spectrum Health April Wolfe [email protected] QC15: Butterworth Hospital Emergency Department: Using Evidence Based Lean Practice to Improve Quality and Throughput Spectrum Health Larah Wildern [email protected] QC16: Canton Warehouse: How 31,000 Unruly Square Feet Accidentally Became a SystemWide Asset Storage Solution Spectrum Health Amy Sequeira [email protected] QC17: Care Coordination Redesign Utilizing LEAN Six Sigma Deaconess Hospital Cathy Seuell, RN [email protected] QC18: Changing the Game Plan for Discharge NCH Health Care System Marie Hageman, RN [email protected] QC19: Charcot Foot: A New Integrated Pathway Solent NHS Trust Eloise Whitaker [email protected] QC20: Chasing Sepsis: Early Recognition and Treatment of Sepsis Outside of Critical Care Hoag Memorial Hospital Presbyterian Andre Vovan, MD [email protected] QC21: Clinical Operations Group Franciscan Alliance Beth Grbavac, RN [email protected] QC22: Colorado’s Critical Access Hospitals and Rural Health Clinics: Improving Communications and Readmissions (iCARE) Colorado Rural Health Center (CRHC) Caleb Murphy Siem [email protected] QC23: Constant Collaboration: Regional HFAP Program Franciscan Alliance Beth Grbavac, RN [email protected] QC24: Continuous Quality Improvement Process Using Heart Failure Core Measures and Computer Generated Palliative Care Triggers NCH Health Care System Shannon Brown [email protected] QC25: Creating One-Piece Flow in the Primary Care Setting University of Texas Medical Branch Gina Butler, RN [email protected] QC26: Customizable, Office-Based Surgical Safety Checklist Improves the Rates of Key Indicators and Outcomes Institute for Safety in Office-Based Surgery Fred Shapiro, DO [email protected] QC27: Dated Color-Coded Labels Cue Nurses to Adhere to Central Line Connector Change NCH Health Care System Jan Foglesong, RN [email protected] QC28: Denials: The Path to Prevent Payers from Saying No to Your Claims Franciscan Alliance Beth Grbavac, RN [email protected] QC29: Design, Implementation, and Monitoring of Clinical Practice Guidelines for Post-Surgical Pain in Adult Patients Hospital Universitario Austral Ana Fajreldines, PharmD [email protected] QC30: Developing a Consistent Method to Measure Ambulatory Space Utilization Across a Pediatric Hospital System Cincinnati Children’s Hospital Medical Center Kathleen Kramer [email protected] QC31: Developing a Staffing Tool for Clinical Leaders of Ambulatory Cancer Centers University of Texas, MD Anderson Cancer Center Tatiana Hmar-Lagroun [email protected] QC32: Discharge Planning: Bridging the Gap Between Hospital and Home Franciscan Alliance Beth Grbavac, RN [email protected] QC33: Driving Transformation by Seeing the System Through the Eyes of Patients and Their Families Toronto Central Community Care Access Centre Jodeme Goldhar [email protected] 25th Annual National Forum on Quality Improvement in Health Care QC34: ED’s PAIN: Reducing Musculoskeletal Pain-Related Non-Urgent ED Visits by a Cleveland VA Medical Home Clinic Louis Stokes VA Medical Center Mary Angelynne Esquivel, MD [email protected] QC35: Early Elective Deliveries: Rate Improvement and Data Collection Standardization Carolinas Health Care System Amy Bell, RN [email protected] QC36: Eliminating the NAUTI CAUTI: Collaboration and Evidence Based Protocols Drive Prevention Gains NCH Health Care System Maureen Baldia, RN [email protected] QC37: Embedding Care Managers in Practice: A Michigan Tale Michigan Primary Care Transformation Project Mary Ellen Benzik, MD [email protected] QC38: Empowering Physicians as Change Agents WhiteCloud Analytics Jason Blumberg [email protected] QC39: Enhanced Patients’ Satisfaction with Reduced Call Abandons The Aga Khan University Hospital, Karachi Muhammad Taha Khan Bangash [email protected] QC40: Enhancing Satisfaction of Patients by Decreasing Clinic’s Length of Stay (LOS) AGA KHAN UNIVERSITY HOSPITAL Raheel Gujrati, MD [email protected] QC41: Epilepsy Monitoring Unit Care: Using Evidence-Based Principles to Improve Quality and Access to Care Spectrum Health System Holly Patterson [email protected] QC42: Evidence-Based Quality Improvement Initiative Results in Significant Decrease in HospitalAcquired Pressure Ulcers Arrowhead Regional Medical Center Frances Dyckman, RN [email protected] QC43: First Year Results of a Performance Improvement Committee for Extra-Corporeal Life Support Houston Methodist Sarah Homer, RN [email protected] QC44: From VAP to VAE: Implementing the 2013 CDC/ NHSN VAE Guidelines in Critical Care NCH Health Care System Chris Raphael, RN [email protected] QC45: Geisinger 7-Day Auto-Dialer Improves Access and Revenue in a Rural Integrated Health System Geisinger Health System John Kennedy, MD [email protected] QC47: Getting to 100%: Standardizing Room Entry on the Intensive Care Unit Beth Israel Deaconess Medical Center Samantha Ruokis [email protected] QC48: Going Vertical: Level 3 Fast Track NCH Health Care System Wendell McClurg, RN [email protected] QC49: Health Staff Capacity Building in Rural Cambodia NHS Thames Valley and Wessex Leadership Academy Claire Greszczuk [email protected] QC50: HFAP Preparedness: A Frontline Focus Franciscan Alliance Beth Grbavac, RN [email protected] QC51: HFAP Standards: Identifying Interactions Franciscan Alliance Beth Grbavac, RN [email protected] QC52: HFAP Survival Guide Franciscan Alliance Beth Grbavac, RN [email protected] QC53: Home Diuretic Protocol for Heart Failure: Partnering with Home Health to Improve Outcomes, Reduce Readmissions MaineHealth Ann Cannon, RN [email protected] QC54: Home-Based Palliative Care Program Long Island Jewish Health System Lori Attivissimo, MD [email protected] QC55: How to Gain MD Involvement in OPPE and Re-credentialing University of Texas, MD Anderson Cancer Center Alma Rodriguez, MD [email protected] QC56: How to Impact Quality with Top Performing Hospital Best Practices Truven Health Analytics David Bordewyk [email protected] QC57: Identifying Waste in Surgical Patients: Unscheduled Returns to the Operating Room Hospital Universitario Austral Maria Teijeiro, MD [email protected] QC58: IMPACT DC: An Intervention and Collaboration to Improve Pediatric Asthma AmeriHealth District of Columbia Mark R. Fracasso, MD [email protected] QC70: Is Osteoporosis in Men Under-Screened? Cleveland Clinic Health System Samta Jain, MD [email protected] QC59: Impact of Computer-Assisted Personalized Sedation on Components of Colonoscopy Procedure Time S2 Statistical Soultions, Inc. Peter Mallow, PhD [email protected] QC560: Improving OR Utilization and First Case On-Time Starts VA Eastern Colorado Health Care System Adam Roberts [email protected] QC61: Improving Outcomes in Patients with Complex Clinical Conditions: Beyond 911 Long Island Jewish Medical Center Rafael Barrera, MD [email protected] QC62: Improving the Subsidized Specialist Outpatient Clinics’ No Show Rate and Optimizing Utilization of Clinic Capacity National University Hospital Donna Joy B Penanueva, MD [email protected] QC63: Improving Throughput and Patient Experience in the Emergency Department Through Process Improvement and Standardization Sarah Bush Lincoln Health System Nancy Wurtsbaugh, RN [email protected] QC64: Improving Time to Therapeutic Vancomycin Trough NCH Health Care System Maria Esposito PharmD [email protected] QC65: Improving Transitional Care in the San Francisco Bay Area Cynosure Health Pat Teske, RN [email protected] QC66: Increasing and Evaluating the Value of Continuous Quality Improvement Through the LHSC Shared Governance Model London Health Sciences Centre Vanessa Burkoski, RN,, PhD [email protected] QC67: Innovation and Change in Hard Times University of Texas, MD Anderson Cancer Center Margaret Bell, RN [email protected] QC68: Integrated Care Pathway (ICP) Programme for Patients with Chronic Obstructive Pulmonary Disease in JurongHealth Alexandra Hospital (Jurong Health) Anne Li Xiao [email protected] QC69: Integrating Supportive Care: It’s Just What We All Do OSF Health Care Robert Sawicki, MD [email protected] QC71: ISO 9001 Standard: A Way to Standardize Your Quality Program Franciscan Alliance Beth Grbavac, RN [email protected] QC72: Keep Pace with Racing Hearts: Get with The Guidelines®-AFIB American Heart Association Louise Morgan, RN [email protected] QC73: Labor and Management Partnering for Quality 1199 SEIU, RN Labor Management Initiatives Robbie Freeman, RN [email protected] QC74: Layout Analysis to Select Transportation Equipment Storage Locations at a Hospital University of Texas MD Anderson Cancer Center Tatiana Hmar-Lagroun [email protected] QC75: Leveraging the Electronic Health Record (EHR) to Reduce Occupational Exposure to Tuberculosis NCH Health Care System Georgine Kruedelbach, RN [email protected] QC76: Managed Care: Bridging the Gap Franciscan Alliance Beth Grbavac, RN [email protected] QC77: Measuring Quality Impovement in Palliative Care Provision in a Tertiary Hospital National Cancer Centre Singapore Patricia Soek Hui Neo, MD [email protected] QC78: MEDS-Medication Education Direct and Simple NCH Health Care System Annie Reynolds, RN [email protected] QC79: Mock Tracer Survey Checklists: A Collaboration Franciscan Alliance Beth Grbavac, RN [email protected] QC78: Modified Resident Scheduling: An Attempt to Reduce Length of Stay Through Increased Provider Continuity Mount Sinai Medical Center Nicole Brown [email protected] QC81: Multi Disciplinary Process Strategies Positively Affect Cardiac Surgery Patients’ Blood Glucose Virginia Commonwealth University Debra Austin, RN [email protected] QC82: Next Generation MapsLink Labor Costs to Waste University of Texas, MD Anderson Cancer Center Gina Aranzamendez, RN [email protected] QC83: NQF’s Lean Journey: Reimagining the Health Care Quality Measure Development and Endorsement National Quality Forum Adeela Khan, MPH [email protected] QC84: Nursing Resource Team: A Resource for Quality Improvement London Health Sciences Centre Sandra Quin, RN [email protected] QC85: Objective Assessment of Incoming Clinical Technology & Devices Geisinger Health System A. Joseph Layon, MD [email protected] STORYBOARDS QC46: Getting the Job Done: Integrating Non-Health Professional Students in Quality Assurance Program Development and Review London Health Sciences Centre Margaret Belliveau, RN [email protected] QC86: Optimizing GI Patient Flow: Procedure Room Turnover BIDMC Michelle Sheppard, RN [email protected] QC87: Our Journey to Standardized, Evidenced-Based Practices for Screening, Early Identification and Intervention for Severe Sepsis Sutter Health Mary Ann Daly, RN [email protected] QC88: Outcomes Following Standardization of Discharge Processes for Patients on Self-Administered OPAT from a Safety-Net Hospital Parkland Health and Hospital System Kavita Bhavan, MD [email protected] QC89: Paradigm Shift in Takling Annual Staff Competency UPMC Sherri Jones [email protected] QC90: Partnering Up: Partnership for Patients Franciscan Alliance Beth Grbavac, RN [email protected] QC91: Pathology and Laboratory Medicine: Reporting Patient Results within Targeted Response Times London Health Sciences Centre Manuella Giuliano [email protected] QC92: Patient Comments Drive Discharge Strategies NCH Health Care System Patty Haines, RN [email protected] QC93: Patient Satisfaction: Spreading Best Practice Franciscan Alliance Beth Grbavac, RN [email protected] Which storyboard did you enjoy? Tweet it using #IHI25Forum 49 STORYBOARDs Storyboard Reception Tuesday, December 10, 4:30 PM – 6:30 PM, Palms Ballroom During this reception, presenters will be standing by their boards to answer questions. QC94: Paying it Forward: Interns for Improvement Franciscan Alliance Beth Grbavac, RN [email protected] QC105: Reducing Harm from Anticoagulant Therapy NCH Health Care System Maria Esposito PharmD [email protected] QC95: Pharmacist-Managed Antimicrobial Stewardship Program for Patients Discharged from the Emergency Department (ED) Memorial Hermann Sara Schepcoff PharmD [email protected] QC106: Reducing Preventable Readmissions by Leveraging Real-Time Predictive Analytics Integrated with a Workflow System SpectraMD Raj Lakhanpal, MD [email protected] QC96: Pharmacy Inventory Control Quality Improvements University of Texas, MD Anderson Cancer Center Dalia Farhat [email protected] QC107: Reducing Ventilator Days Using Lean Six Sigma Robert Packer Hospital Nicole M. Teeter, RN [email protected] QC108: Reduction in CLABSI in Children with Intestinal Failure Through Implementation of a CLA-BSI Prevention Bundle Nationwide Children’s Hospital Jeff Lewis, RN [email protected] QC97: Physician Scorecards: Trending in the Right Direction Franciscan Alliance Beth Grbavac, RN [email protected] QC98: PI: Making a Digital Footprint Franciscan Alliance Beth Grbavac, RN [email protected] QC99: Putting on the Pressure: Management and Prevention of Pressure Ulcer for the Acute Rehabilitation Patient NCH Health Care System Nancy Davison, RN [email protected] QC100: Quality & Effectiveness of Electronic Wound Documentation System (EWDS): Innovating for the Future Responsive Management Inc Debbie Green [email protected] QC101: Quality Improvement for Portable Chest X-Ray Bumrungrad International Punthika Karnsomdee, RN [email protected] QC102: Quiet in the House! NCH Health Care System Meredith Burt, RN [email protected] QC103: Rebooting Physician Hardware Process Franciscan Alliance Beth Grbavac, RN [email protected] QC104: Reducing Costs & Improving Quality Franciscan Alliance Beth Grbavac, RN [email protected] 50 QC109: Reduction in Health CareAssociated Transmission of Tuberculosis (Tb) to Health Care Workers in Tertiary Care Hospital The Aga Khan University Hospital Suneina Musani [email protected] QC110: Room Occupancy Management System (ROMS): Use Them (Lights) or Lose Them (Patients) Mayo Clinic Andrew Majka, MD [email protected] QC111: Safe, Effective, & Well Coordinated Patient Transition After Total Joint Replacement: A “Discharge Appointment” MidState Medical Center Dawn Plumb, RN [email protected] QC112: Same Day Discharge after Pediatric Appendectomy: Fast Track Appendectomy All Children’s Hospital Julie Messick, RN [email protected] QC113: Sepsis Identification/ Intervention: The Clock is Ticking Franciscan Alliance Beth Grbavac, RN [email protected] QC114: Slenderize Health Care Associated Infection Surveillance System Bumrungrad International hospital Junya Charayopas, RN [email protected] QC115: Smart Room Technology: Giving Time Back to the Nurse NCH Health Care System Peter Olsen, RN [email protected] QC127: Trends in Disparities in Care at Academic Medical Centers University HealthSystem Consortium Leslie Prellwitz [email protected] QC116: Something to Talk About: Medication Education NCH Health Care System Dave Baryza, RN [email protected] QC128: Triaging Robotic Surgery Based on Evidence-Based Clinical Outcomes Improves Resource Utilization Banner Health System David Edwards, MD [email protected] QC117: Staying Ahead of Falls Franciscan Alliance Beth Grbavac, RN [email protected] QC118: Strategies to Increase Awareness of Saturday Urgent Care Clinic University Health Network Miu Lin Wong [email protected] QC119: Stroke Care Excellence to Achieve the Triple Aim: Re-Engineered Preventive and Hospital Care Stanford Clinical Excellence Research Center Jared Conley [email protected] QC120: Supply Waste Reduction: A Lean Six Sigma Improvement Project Our Lady of Lourdes Regional Medical Center Cecile Broussard, RN [email protected] QC121: Systems and Human Factors Engineering Approach to Reducing CAUTI Health Care Associated Infections University of Texas Southwestern Medical Center Chanhaeng Rhee,, MD, MD [email protected] QC122: Teaching Personal Protective Equipment (PPE) to Visitors NCH Health Care System Julie Amundson, RN [email protected] QC123: Team Approach to Reducing Surgical Site Infections in Hip and Knee Total Joint Replacement Procedures NCH Health Care System Georgine Kruedelbach, RN [email protected] QC124: The Agency for Health Care Research and Quality Health Care Innovations Exchange (AHRQIX) Westat Deborah Carpenter, RN [email protected] QC125: Time is Muscle: Reducing Harm with Lean Six Sigma Robert Packer Hospital Pamela Orshaw, RN [email protected] QC126: To Ensure 100% Accuracy in Recording for Services Rendered Singapore General Hospital Calvin Liu Chee Piow [email protected] 25th Annual National Forum on Quality Improvement in Health Care QC129: Troponin in the Emergency Department: Maintaining Quality While Decreasing Turnaround Time and Cost The Heart Hospital Baylor Pamela Tassan [email protected] QC130: Using Technology to Implement Best Practices for Blood Transfusions HealthPartners, Regions Hospital Lynne Preese [email protected] QC131: Utilizing Technology to Reduce Medication Errors in Chemotherapy Drug Preparation University of Texas, MD Anderson Cancer Center Miguel Lozano [email protected] QC132: Variation Reduction and Value Unit Scales: An Innovative Approach to Quality and Total Cost Measures Palo Alto Medical Foundation Veko Vahamaki DO [email protected] QC133: Video Surveillance: Improving Safety and Quality While Reducing Expenses NCH Health Care System Jordan Mayberry, RN [email protected] QC134: Volume to Value: The Challenges Associated with Negotiating Bundled Payments Utilizing Harvard’s TDABC Methodology Connecticut Joint Replacement Institute Maureen Geary [email protected] QC135: Waging the War on Inappropriate Warfarin Use Franciscan Alliance Beth Grbavac, RN [email protected] QC136: Working Well-TPE Partnership: Achieving Performance Excellence and Earning a Regional Baldrige Award in the Process Franciscan Alliance Beth Grbavac, RN [email protected] QC137: Would You Like a Lactate? Boosting Lactate Measurement in the ED for Early Sepsis Recognition St. Michael’s Hospital Melissa McGowan [email protected] QC13: You Need a SCD for VTE? Franciscan Alliance Beth Grbavac, RN [email protected] Improvement Capability IC5: A Resident Initiative to Increase Use of Naltrexone for Alcohol Use Disorder San Francisco General Hospital Shilpa M. Shah, MD [email protected] IC6: A Trinity of Engagement Transforms Care at UPMC Shadyside’s 6 Main UPMC Irma D’Antonio, RN [email protected] IC7: Addressing Childhood Obesity in the Primary Care Setting: Are We Measuring Up? Texas Tech University Health Sciences Center Tracey Page, RN [email protected] IC8: Aligning Communication Among Health Care Professionals During the Performance of Fetal Health Surveillance London Health Sciences Centre Margaret Belliveau, RN [email protected] IC9: Apply Lean to Streamline Breast Imaging Processes: To Reduce Patients’ Waiting Time Singapore General Hospital Chan Lee Lee [email protected] IC10: Building a Better Emergency Department Seattle Children’s Hospital Dawn Cotter, RN [email protected] IC11: Building Capacity for Sustained Improvement in Acuity Adaptable Critical Care Unit: Focused Applied Coaching Geisinger Health System Tracy Edelstein, RN [email protected] IC14: Closing the Gap: Aligning Education and Process Improvement in Clinical Practice Close Care Gap Kate ONeill, RN [email protected] IC15: Committee System Transformation Using SBAR, a Standardized Communication Tool Vancouver Island Health Authority Shawna Adams [email protected] IC16: Cytotoxics: Keeping Staff and Patients Safe London Health Sciences Centre Jennifer Yoon, RN [email protected] IC17: Declining Resilience Among Health Care Workers May Jeopardize Teamwork and Safety Improvement Sustainability Adventist Health Joanna Bokovoy, RN [email protected] IC18: Developing and Sustaining an Effective Orientation Process in Health Care Geisinger Health System Kelly Cresci [email protected] IC19: Dramatic Decrease in Clinic Verification Time Resulted in Preventing Workaround and Improvement of Patient Safety SEHA Azhar Talal RPh [email protected] IC20: Driving Quality and Service Improvement Through Physician Education and Performance Evaluation Gundersen Health System Marilu Bintz, MD [email protected] IC21: Effecting Patient Experience Through eLearning for the Care Team Remedy Healthcare Consulting Sheila Richmeier, RN [email protected] IC22: Emergency Department: Door to Provider in Less Than 15 Minutes Seattle Children’s Hospital Dawn Cotter, RN [email protected] IC23: Enhancing Care Team Communication University of Pennsylvania Hospital Neha Patel, MD [email protected] IC24: Ensuring Quality in the Nurse-Managed Pre-Pre Analytic Specimen Collection Phase Sunquest Information Systems JoAnne Scalise, RN [email protected] IC25: Evidence-Based Spiritual Care Training London Health Sciences Centre Jill McTavish [email protected] IC36: Is Health Care Really Different? A Perspective from a Veteran Black Belt Guthrie Clinic Jonathan Meigs [email protected] IC37: Leadership for Changing Times: Staff-Led, LeadershipSupported Improvement St. Joseph’s Health Centre Julie Ninnis, RN [email protected] IC26: Facilitating Easy Disposal of Oro-Pharyngo-Tracheal Suctioning Requisites Singapore General Hospital Sa’adiah Binte Arsad RN [email protected] IC38: Making Metrics Meaningful: “I Impact the Organization’s Goals” BIDMC Michelle Sheppard, RN [email protected] IC27: From Volume to Value: Academia Meets the Community Columbia HeartSource Paul Kurlansky, MD [email protected] IC28: High Reliability Organizations Require Dream Teams Courtemanche & Associates Nancy McLean, RN [email protected] IC29: HIV Screening: Using QI to Enhance Teamwork in a VA Medical Home Clinic Louis Stokes VA Medical Center Moshe Ornstein, MD [email protected] IC30: Holistic Value Stream Mapping Using Enterprise Architecture Methodologies Guthrie Health System Dennis Robi [email protected] IC31: Implementation of an In-House Certification Program for New Operating Room Registered Nurses London Health Sciences Centre Sandra Harwood, RN [email protected] IC32: Improving Nursing Compliance of Pain Reassessment (60 minutes of Opioid Administration); Maternity and Medical/Surgical Units Intermountain Health Care Mary Zeigle [email protected] IC33: Improving Outpatient Cardiac Rehabilitation Program Referrals Post Myocardial Infarction The Heart Hospital Baylor Plano Kristi Verschelden, RN [email protected] IC34: Improving Quality Improvement Residency Education and Provider Performance Through a Shared Online Experience Duke University Medical Center Jonathan Bae, MD [email protected] IC35: Introduction of a Structured Orientation Programme for Registered Nurses in a Community Hospital in Singapore Bright Vision Hospital, Singapore Salimah Binte Mohd Ayoob, RN [email protected] STORYBOARDS IC1: A Campaign to Raise Awareness of Health Care Disparities Henry Ford Health System Megan Brady [email protected] IC2: A Foundation in Quality Improvement North Bristol NHS Trust Benjamin Plumb [email protected] IC3: A Model for Improving the Outpatient Experience University of Texas, MD Anderson Cancer Center Sue Ferguson, RN [email protected] IC4: A Nationwide Clinical Quality Improvement Pilot: Improving Screening for Chlamydia Planned Parenthood Federation of America Mytri P. Singh [email protected] IC12: Centralized Clinical Education Model at London Health Sciences to Achieve Quality Outcomes London Health Sciences Centre Vanessa Burkoski, RN,, PhD [email protected] IC13: Change Agent Fellowship Contra Costa Regional Medical Center Amber Owens [email protected] IC39: Making the Case for Change: Developing an Integrated, Territory-Wide Chronic Disease Management Strategy Canadian Foundation for Health Care Improvement Jennifer Verma [email protected] IC40: MD Anderson’s Quality Improvement Curriculum University of Texas, MD Anderson Cancer Center Robert Joyce [email protected] IC41: Mentoring Effective Implementation of the SLMTA Program at the Country Level for Vietnam and Cambodia Global Health Consulting BCM Barbara McKinney, MD [email protected] IC42: Meta-Management II: Management for Management Using Checklist Based on IS0 9001 Aso Iizuka Hospital Hiromi Ando, MD, PhD [email protected] IC43: Mobile Technology: Facilitating Patient Care and Increasing Productivity London Health Sciences Centre Minakshi Sharma [email protected] IC44: Nurse-Led Fast Track in Emergency Department Southern District Health Board Leanne Samuel, RN [email protected] IC45: Optimizing AECOPD Care Through Collaboration, Innovation, and Process: A Regional Perspective from British Columbia, Canada South Okanagan Similkameen Division of Family Practice Shannon Walker, MD [email protected] IC46: Our Journey Towards Quality Improvement and Implementation Region Zealand Hospital Naestved, Slagelse and Ringsted Helmer Buchardt Pedersen, MD [email protected] IC47: Performance and Quality Improvement Using the DMADV Methodolgy Health Care Improvement Providers LLC Sean Anzuoni Sean@Health Carepqs.com Which storyboard did you enjoy? Tweet it using #IHI25Forum 51 STORYBOARDs Storyboard Reception Tuesday, December 10, 4:30 PM – 6:30 PM, Palms Ballroom During this reception, presenters will be standing by their boards to answer questions. IC67: Women’s Clinic Laboratory Sample Collection Process Redesign to Reduce Collection Errors Kaiser Permanente Santa Clara Medical Center Francisco Rodriguez [email protected] Leadership IC48: ProvenCare® Lumbar Spine: A Mesosystem Approach to Improving Outcomes Geisinger Health System Kelley Morrison, RN [email protected] IC49: Radiography Complete Patient Histories to Improve Diagnosis Cincinnati Children’s Hospital Medical Center Wendy Bankes [email protected] IC50: Redesigning the Emergency Department to Improve Door-to-Doc Time and Patient Satisfaction Intensimed Amilcar Mocelin, MD [email protected] IC51: Reducing Arthroscopes’ Repairs in Major Operating Theatre and Ambulatory Surgery Centre in Singapore General Hopsital Singapore General Hospital Seah Xueli Eileen [email protected] IC52: Reducing the Frequency of Replacing Damaged Case Notes Folder Singapore General Hospital Tan Lee Eng Priscilla [email protected] IC53: Strategies to Implement Complimentary Bedside Safety Initiatives Using Kotter’s Change Model University of Wisconsin Hospital and Clinics Anne Mork, RN [email protected] IC54: Streamlining Health Metric Collection to Strengthen Project Monitoring and Evaluation in an NGO Setting Thames Valley and Wessex NHS Leadership Academy Adam Barnett [email protected] IC55: Student Experience: Systems Design for Non-Medical Student Placements London Health Sciences Centre Kelly Ainge [email protected] IC56: Systematic Approach to Assess Sink Availability and Accessibility in a Multi-Hospital System Orlando Health Scott Brown, RN [email protected] IC57: The Cervical Smear Program in a Low Income and Developing Population: A South African Perspective Improving Global Health Ann-Marie Streeton MB ChB [email protected] 52 IC58: The Culture Connection: Combining a Culture of Safety & Just Culture to Create High Reliability Courtemanche & Associates Darlene Christiansen, RN [email protected] IC59: The Effect of Using the Lean Tools in the Emergency Department of a Saudi Hospital The Royal Commission Health Services Program - Yanbu Industrial City Alber Paules, MB ChB [email protected] IC60: The Geisinger Quality Institute: Improving Dischagre Times Through a Collaborative Microsystem Improvement Approach Geisinger Wyoming Valley Medical Center Daniel Amorino [email protected] IC61: Triad Models for Quality: The Shape of Things to Come Orlando Health Anne Peach, RN [email protected] IC62: Two New Hospitals: A Lean Six Sigma Approach to Transition Corning Hospital Megan Hawkins, RN [email protected] IC63: UC Davis Health System Journey to Patient Centered Medical Home to Improve the Patient Experience University of California Medical Center Angela Gandolfo [email protected] IC64: Using the Patient Safety Education Program to Improve Leadership Engagement and Execution of QI Processes Institute for Public Health and Medicine, Northwestern University Mitesh B. Rao, MD [email protected] IC65: Using Multidisciplinary Collaborative Models to Eliminate Central Line Associated Bloodstream Infections in Non-ICU Medical-Surgical Wards Cedars-Sinai Medical Center Claude Killu, MD [email protected] IC66: Using Six Sigma to Improve Safety in the Patient Surgical Experience North Shore Long Island Jewish – Huntington Hospital Corazon R. Paraso, RN [email protected] L1: First Things First: What is the Current Reality? Carolinas Health Care System Colleen Hole, RN Colleen.Hole@carolinasHealth Care.org L2: Medical Control Protocols as a Foundation for Quality Management Alberta Health Services (Emergency Medical Services) Glenn McRae, RN [email protected] L3: Prioritizing Cancer Quality Measures University of Texas MD Anderson Cancer Center Lisa Kidin, RN [email protected] L4: Safety Programme Inducing Organisational Culture Change Lillebaelt Hospital Dorthe Cruger, MD, PhD [email protected] L5: Using Cross-Institutional Learning to Reduce Surgical Site Infection Rates in Pennsylvania York Hospital Vanita Ahuja, MD [email protected] Patient Safety PS1: A Community Hospital’s Approach to Infection Prevention Flagler Hospital William Hepler, RN [email protected] PS2: A Multidisciplinary Approach to Improve Anticoagulation Safety: Improving Patient Re-Engagement and Adherence to Care Plan Beth Israel Deaconess Medical Center Diane M. Brockmeyer, MD [email protected] PS3: A New Collaborative Improvement Model: Leading to Success in California Hospitals California Hospital Association/ Hospital Quality Institute Sandra Trotter [email protected] PS4: Addressing Critical Lab Values After Regular Practice Hours: Improving Communication and Care Woodhull Medical and Mental Health Center Jonah Green, MD [email protected] PS5: Adverse Drug Event Reduction Through Guardrail Infusion Pump Auditing and Just-In-Time Education Children’s National Medical Center Valere Lemon, RN [email protected] 25th Annual National Forum on Quality Improvement in Health Care PS6: Air Transport of Large Patients: Guidelines to Keep Patients and Staff Safe University of Michigan Health System Kathleen Lanava [email protected] PS7: Alert Signs Prior to Death in Ward-Patients Recovering from Postoperative Orthopedic Surgery Instituto Nacional de Traumatologia e Ortopedia Luciana Carvalho [email protected] PS8: Ambulatory Medication Reconciliation: A Collaborative Approach Brigham and Women’s Hospital Caroline Keogh, RN [email protected] PS9: Assisting with the Assist Device: Implementation of a Training Program on Ventricular Assist Devices London Health Sciences Centre Rachelle Mccready, RN [email protected] PS10: Auditory Responses to Everyday Sounds in Patients with Chronic Pain Simon Fraser University Mark Nazemi [email protected] PS11: Checklists and Quality Outcomes Correlation Versus Causation—One Year Later Geisinger Health System A. Joseph Layon, MD [email protected] PS12: Communication Between the Emergency Department and Long-Term Care Facilities: Improving Transitions in Care London Health Sciences Centre Leon Petruniak, RN [email protected] PS13: Comparison of Normal Saline and Heparinised Saline Flush for Arterial Catheter in Adult Patients National Heart Centre Singapore Jasmine Lee, RN [email protected] PS14: Construction of the Patient Safety Policy of the Sao Camilo Hospital Rede de Hospitais Sao Camilo Daniela Akemi Costa [email protected] PS15: Data Analysis Drive Project Prioritization for Improved Patient Flow Health Sciences North Shannon Kenrick-Rochon, RN [email protected] PS16: Decreasing MRSA Colonization in the Intensive Care Nursery Hospital of the University of Pennsylvania Michael Posencheg, MD [email protected] PS17: Delirium Bundle Implementation: Report of a Medical-Surgical ICU Sao Camilo Leonardo Brauer, MD [email protected] PS18: Destroying the State of Sepsis MedStar Washington Hospital Center Sally Gutierrez, RN [email protected] PS20: Do Mock Drills Prepare Health Care Workers (HCWs) for Actual Medical Emergencies? The Aga Khan University Hospital Rozina Roshan Essani, RN [email protected] PS21: Driving a Microsystem Improvement Portfolio The Children’s Hospital of Philadelphia Debra Geiger [email protected] PS22: Drug Recall Notification: A Comprehensive Program in Ambulatory Care North Shore-LIJ Health System Leonard Langino RPh [email protected] PS23: Early Mobility of Critically Ill Patients in a Community Hospital Mayo Clinic Health System - Mankato Erin Brokl, RN [email protected] PS24: Effects of Rapid Response Team Activation Training in a General Hospital Sao Camilo Camila Paiva de Vasconcelos, MD [email protected] PS25: Electronic Surgical Safety Checklist Ensures Adoption LiveData, Inc. Jeff Robbins [email protected] PS26: eMEWS Triggers Appropriate Monitoring & Care Escalation North Shore-LIJ Health System Kevin Bock, MD [email protected] PS27: Encouraging Reporting Through Visible Improvements Juronghealth Services Andie Zhang Zhixuan [email protected] PS28: Enhancing Quality and Safety through Walkabouts at Health Sciences North Health Sciences North Shannon Kenrick-Rochon, RN [email protected] PS29: Falls Which Led to Lesions in Orthopedic Patients Admitted to Hospital in Rio de Janeiro Instituto Nacional de Traumatologia e Ortopedia Luciana Carvalho [email protected] PS30: Fighting CLABSI: An Interdisiplinary Approach for Best Practice Outcomes Cancer Treatment Centers of America Deborah Baldassarre, RN [email protected] PS55: Incorporating IOM/QSEN Competencies into a Nurse Residency Program Versant Holdings, LLC Larissa Africa, RN [email protected] PS32: Foley Catheter Removal North Shore Medical Center Michael D. Medlock, MD [email protected] PS33: Gaps in Cardio Pulmonary Resuscitation (CPR) Documentation: A Step Towards Reducing Risk of Legal Implications The Aga Khan University Hospital Rozina Roshan Essani, RN [email protected] PS44: Improvement in Hand Hygiene Compliance: An Institution Wide Initiative for Patient Safety The Aga Khan University Hospital Suneina Musani [email protected] PS45: Improving Care of High-Risk Inpatients: A Pilot Study North Shore Long Island Jewish Health System Sienna Moran, MD [email protected] PS56: Increasing the Percentage of Patients Post Laparotomies for Non-Malignant Disorders Discharged on Fourth PostOperative Day Singapore General Hospital Punasundri D/O Thangaraju [email protected] PS34: “Growing is in Progress: Reduction in Elective Deliveries Less than 39 Weeks” Sarasota Memorial Hospital Renee Maietta [email protected] PS46: Improving Communication and Learning Between Hospital Health Team and the Inpatient Clinica San Felipe SA Ernesto Aspillaga, MD [email protected] PS35: Guidewires Unintentionally Retained During Central Venous Catheterization UHC Tammy Williams, RN [email protected] PS47: Improving Current Leg Elevator (Braun Frame) Singapore General Hospital Rosida Binte Jantan [email protected] PS48: Improving Hospital Acquired Pressure Ulcers (HAPU) Through Monitoring and Management (A Initiative) The Aga Khan University Hospital Yasmin Vellani, RN [email protected] PS36: Happie Lappie! Singapore General Hospital Shahidah Bte Roslan [email protected] PS37: High Risk Neonatal Transitional Care Model for Quality Improvement London Health Sciences Centre Sheeva Woznuk, RN [email protected] PS38: How Low is Too Low? The Overtreatment of Diabetes Mellitus in the Elderly Louis Stokes VA Medical Center/Cleveland Clinic Foundation Tania Jaber, MD [email protected] PS39: I-PASS: Creation, Implementation, and Dissemination of a Bundled Handoff Intervention University of Toronto Trey Coffey [email protected] PS40: Implementation of the Sepsis Six Pathway for Severe Sepsis Gloucestershire Hospital NHS Foundation Trust Andrew Seaton, RN [email protected] PS41: Implementing a Purposeful Pause at Hospital Discharge York Hospital Dawn Becker, RN [email protected] PS42: Implementing and Sustaining an Effective VAP Prevention Bundle Nationwide Children’s Hospital Randall Frost [email protected] Improved Compliance with Heart PS49: Improving Medication Administration Safety in a Community Hospital Using Lean Methodology Headwaters Health Care Centre Sandy Critchley [email protected] PS57: Integration of EvidenceBased Health Care and Quality Improvement Strategies in Falls Reduction in NUH, Singapore National University Hospital Siti Zubaidah Bte Mordiffi [email protected] PS58: It Takes a Team: Failure to Involve PT/OT and Readmission Risk University of Minnesota Medical Center Neal Boeder, MD [email protected] PS59: “It’s Not A Hard Pill to Swallow”: Implementing a Bedside Swallowing Screen for Acute-Stroke Care London Health Sciences Centre Lynda Ryall-Henke, RN [email protected] PS60: Knock Out Fall Incidence Singapore General Hospital Nur Jannah Zhong Yarui, RN [email protected] PS61: Less is Morphine: Enhancing by Decreasing Opioid Related Incidents Sunnybrook Health Sciences Centre Trevor Hall, RN [email protected] PS50: Improving Nurses’ Knowledge in Management of Patients with Pressure Ulcer(s) in Ward 64 by 30% Singapore General Hospital Yan Na, RN [email protected] PS62: Long-Term Improvement of Central Line Associated Blood Stream Infections at Bumrungrad International Hospital Year 2002-2012 Bumrungrad International hospital Junya Charayopas, RN [email protected] PS51: Improving Patient Safety by Implementation of Pre-Procedure Time Out Verification at Endoscopy Suite The Aga Khan University Hospital Sumaira Sachwani, RN [email protected] PS63: Making Sure Safety Culture Assessment Benefits Improvement Efforts Det Norske Veritas (DNV) Tita Alissa Listyowardojo, PhD [email protected] PS52: Improving Quality of Afghanistan Primary Health Care Through Standard Based Management and Recognition Mohammad Basir Farid [email protected] PS64: Med Rec or Med Wreck: Making Medication Reconciliation Work in the Cardiac Surgery Population London Health Sciences Centre Anne McVety, RN [email protected] PS53: Improving Surgical Site Infections in the Colon Surgery Population North Shore Medical Center Ninamarie Qualtieri, RN, RN [email protected] PS65: Mislabeled Specimens: One Institution’s Story The Hospital of Central Connecticut Kathy Scrittorale [email protected] PS65: Navigating the Challenges of Patient Flow and Boarding in Hospitals The Joint Commission Patricia Adamski, RN [email protected] PS54: Including Patients and Families as Part of Team Approach to Fall Prevention Brigham and Women’s Hospital Escel Stanghellini, RN [email protected] STORYBOARDS PS19: Developing & Enhancing Utilization of Written Discharge Instructions (DIs): An Initiative The Aga Khan University Hospital Rozina Roshan Essani, RN [email protected] PS43: Failure Quality Indicators at a Brazilian Non-Teaching Private Hospital Hospital Israelita Albert Einstein Alessandra Correa, RN, PhD [email protected] PS31: First National Survey of Patient-Controlled Analgesia Practices Physician-Patient Alliance for Health & Safety Michael Wong [email protected] Which storyboard did you enjoy? Tweet it using #IHI25Forum 53 STORYBOARDs Storyboard Reception Tuesday, December 10, 4:30 PM – 6:30 PM, Palms Ballroom During this reception, presenters will be standing by their boards to answer questions. PS67: New Hospital Activation Using Human Patient Mannequin Simulation to Evaluate Patient Workflow and Safety VHA Yasuharu Okuda, MD [email protected] PS68: Nursing Survey Revealed Novel Strategy Assists in Adherence to Best Practices of CVC Dressing Management Cookeville Regional Medical Center Jamie Deneau [email protected] PS77:Pilot Study to Assess Risk for Aspiration of Enteral Contrast for Diagnostic Tests Orlando Health Thomas Kelley, MD [email protected] PS78: Planning the Education of Patients and Relatives at INTO: A Strategy for Full Attention Instituto Nacional de Traumatologia e Ortopedia Luciana Carvalho, RN [email protected] PS69: Offensive Talks, Attitudes Affects on Older People The American Academy on Communication in Health Care Sofica Bistriceanu, MD, PhD [email protected] PS70: One Size Fits All? The Improvement Sciences Approach North Shore Long Island Jewish – Lake Success Nancy Riebling [email protected] PS79: Post Orientation Mini Master Rotation (POMMR) There is “Light at the End of the Tunnel” London Health Sciences Centre Karen Burnett, RN [email protected] PS80: Pressure Ulcer Improvement Process North Shore Medical Center Greg Conklin, RN [email protected] PS71: Patient Safety First… A California Partnership for Health National Health Foundation Heidi Fischer [email protected] PS72: Pediatric Skin Injury Reduction in the Operating Room Nationwide Children’s Hospital Mike Fetzer [email protected] PS73: Perception & Barriers Regarding Self-Signed and Relative Signed Informed Consent (IC): A Comparative Study The Aga Khan University Hospital Rozina Roshan Essani, RN [email protected] PS74: Performance Improvement Through Simulation Education Medical Simulation Corporation Arthur Childs, MD [email protected] PS75: Permanent Kaiser: Helping the Identification of Environmental Risks and Hospital Safety at INTO Instituto Nacional de Traumatologia e Ortopedia Luciana Carvalho [email protected] PS76: Pharmacist Medication Reconciliation Involving CHF Patients North Shore Medical Center Andrea Barayuga-MacLean, PharmD, RPh [email protected] 54 PS81: Pressured Over Pressure Ulcers?: Eliminating Hospital Acquired Pressure Ulcers in Saudi Patients at NGHA AL Ahsa National Guard Health Affairs Eastern Region Jamellah Gimenez, RN [email protected] PS82: Preventing Non-Ventilator Hospital Acquired Pneumonia with an Oral Care Intervention Sutter Medical Center, Sacramento Barbara Quinn, RN [email protected] PS83: Quality Improvement and (QIPS) Initiatives at Division of Nursing Services: An Overview The Aga Khan University Hospital Rozina Roshan Essani, RN [email protected] PS84: Re-Engineering Outpatient Parental Antimicrobial Therapy (OPAT): A Process Change for Better andSafe Care Mayo Clinic Deborah C. Beck, RN [email protected] PS85: Reduce Insulin Related Adverse Drug Events (ADE) Using Quality Improvement (QI) Initiatives Nationwide Children’s Hospital Jenna Merandi PharmD, RPh [email protected] PS86: Reducing Drug Administration Interruptions: An Intervention Study University of Verona Francesca Moretti [email protected] PS87: Reducing Incidence of Retained Surgical Instruments in York Hospital’s Operating Room WellSpan Health,York Hospital Virginia Wesner [email protected] PS88: Reducing Pain and Discomfort for Patients with Scrotal Swelling Singapore General Hospital Lee Teng Teng [email protected] PS89: Reducing Radiation Dose in Pediatric Appendicitis CT North Shore Medical Center John Murray, MD [email protected] PS90: Reducing Retained Surgical Sponges Using Sponge ACCOUNTing Hospital Sisters Health System Darren Barnes, RN [email protected] PS91: Reducing Sedation for Vented ICU Patients North Shore Medical Center Lee Anne Fredericks, RN [email protected] PS92: Reducing Transmission of Antibiotic-Resistant Organisms (AROs) Through Daily Antiseptic Patient Bathing Rouge Valley Health System Paula Raggiunti, RN [email protected] PS93: Registered Nurses’ Knowledge on the Administration of Biologic Drugs: An Audit Survey Singapore General Hospital Nurshifa Binte Shaik Hussain [email protected] PS94: Residents as Drivers of Outpatient Practice Improvement: A Unique Solution to Promoting High Quality Care Beth Israel Deaconess Medical Center Joshua Allen-Dicker, MD [email protected] PS95: Respect for People: Shining a Light in a Dark Place Spectrum Health Gail Greco-Bieri [email protected] PS96: Right Patient – Right Care: Preventing Patient Identification Errors in Medical Records Aga Khan University Hospital Saba Dossani, RN [email protected] PS97: Safely Speaking: Improving the Culture of Through Storytelling Medical University of South Carolina Chris Rees [email protected] PS98: Safety Culture and Lean Daily Management Tenet Healthcare Corporation Patrick Smith, MD [email protected] PS99: Safety: Every Patient, Every Time: A Leading Catholic Health System’s Journey to Safety Culture Improvement CHE Trinity Health Theresa Aldini, RN [email protected] 25th Annual National Forum on Quality Improvement in Health Care PS100: Sign of the Times—Making Cytotoxic Safety Visible London Health Sciences Centre Monica Kaszycki, RN [email protected] PS101: SOS: Save Our Skin—A Pediatric Pressure Ulcer Prevention Program Ann & Robert H. Lurie Children’s Hospital of Chicago Ann & Robert H. Lurie [email protected] PS102: Spreading Best Practice for Prevention of Central Line Associated Blood Stream Infections Yale-New Haven Hospital Carrie Guttman, RN [email protected] PS103: Standardizing Perioperative Hand-Off Communication Baylor Medical Center At Irving Courtney Sheward, RN [email protected] PS104: Starting the Week off Right: Monday Morning Huddle to Improve Patient Safety Windsor Regional Hospital Corry O’Neil, RN [email protected] PS105: Surgery Safety Checklist in High Risk/Volume OR University of Texas, MD Anderson Cancer Center Charles F. Levenback, MD [email protected] PS106: Survey on Culture— Comparing Years Rede de Hospitais Sao Camilo Daniela Akemi Costa [email protected] PS107: Tackling Sepsis Through a Nurse Driven Approach UPMC Shadyside Denise Stromoski, RN [email protected] PS108: The Brazilian Sign Language (LIBRAS) DEAF—and its Application at INTO: A Case Report Instituto Nacional de Traumatologia e Ortopedia Luciana Carvalho [email protected] PS109: The Highs and Lows of Resuscitation Journey in National University Hospital (NUH) National University Hospital Bhuvaneshwari Mohan Kumar [email protected] PS110: The Northwest Dialysis Bloodstream Infection Prevention Collaborative Oregon Commission Melissa Parkerton [email protected] PS111: TransCu O2 Wound Healing in Long Term Care Responsive Management Inc. Debbie Green [email protected] Person- and Family-Centered Care PF1: A Primary Care Approach to Tobacco Education and Smoking Cessation in Samlout, Cambodia Oxford Health NHS FT Shoba Subramanian [email protected] PF2: A Scalable Advance Care Planning Initiative Twin Cities Medical Society/Honoring Choices Minnesota Sue Schettle [email protected] PF3: Activation in Vulnerable Patients with Chronic Respiratory Disease (COPD/Asthma) Fletcher Allen Health Care/OneCare Vermont Vicki Loner, RN [email protected] PF4: Aligning Goals of Care VA Palo Alto Health Care System Ruchir Shah, MD [email protected] PF5: An Automated Wellbeing and Service Follow-Up Solution That Facilitates ED Case Management Edward Hospital Tom Scaletta, MD [email protected] PF6: An Interprofessional Approach to Behavioral Emergencies at the University of Virginia University of Virginia Health System Gabrielle Marzani-Nissen, MD [email protected] PF7: An Online Platform for Meaningful Engagement with Patients and Communities: IdeaExchange.sw.org Scott & White Health Care Angie Hochhalter, PhD [email protected] PF8: Asynchronous Web Visits for Chronic Conditions: Implementation in a Busy Primary Care Practice Partners Health Care Ronald Dixon, MD [email protected] PF9: Building and Spreading a Family Caregiver Education Program Henry Ford Health System Sheila Daley, RN [email protected] PF10: Embedding Shared Decision Making in Early Breast Cancer Care Cardiff and Vale University Health Board Helen McGarrigle, RN [email protected] PF11: Enhancing the Patient Experience in an Outpatient Cancer Center University of Texas, MD Anderson Cancer Center Jeremy Meade [email protected] PF12: Enhancing the Patient Voice at St. Joseph’s Health Care Hamilton St. Joseph’s Health Care Hamilton Michelle Joyner [email protected] PF13: Get a Grip! Central Manchester University Hospitals NHS Foundation Trust Jane Mottershead, RN [email protected] PF14: Improve Patient Experience and Reduce Readmissions with Better Discharge Communication Cullman Regional Medical Center Cheryl Bailey [email protected] PF15: Improving Communication for Patient Engagement Rede de Hospitais Sao Camilo Daniela Akemi Costa [email protected] PF16: Improving the Patient Experience Through Better Cancer Symptom Management: A System Wide Improvement Collaborative Cancer Care Ontario Reena Tabing [email protected] PF17: LEAN On Me: Practical Strategies for Improving Patient Satisfaction Through Improved Emotional Support Windsor Regional Hospital Ralph Nicoletti [email protected] PF22: Managing Referrals for Psychological Services for Patients on the Behavior Medicine Service Waiting List London Health Sciences Centre Felicia Otchet, PhD [email protected] PF35: Validating the Patient Experience with Race, Language and Ethnicity Collection University of California Medical Center Angela Gandolfo [email protected] PF24: Patient Engagement and Population Health: Leveraging Technology to Improve Preventive Screening Rates Emmi Solutions Jordan Dolin [email protected] PF25: Patient Navigation—Oncology Rehabilitation Samaritan Hospital – St. Peterâ™s Health Partners Sabrina Mosseau, RN [email protected] PF36: Watch and Wait Without Wonder: Improving Communication for Family Members in an Outpatient Surgical Setting Mayo Clinic Pamela Maxson [email protected] PF26: Patients as Change Agents: A Model for Engagement from Humboldt County, CA Aligning Forces Humboldt at the California Center for Rural Policy Jessica Osborne-Stafsnes [email protected] PF27: Personalization in Health Care: Lessons from Industry Western University Karin Schnarr [email protected] PF28: Pitfalls in the Informed Consent Process: Achieving “PatientCentricity” for Informed Consent Datix Daniel Cohen, MD [email protected] PF18: Legal & Health Literacy Issues During Registration Novant Health Thomas Bauer [email protected] PF19: Leveraging Patient-Specific Knowledge as Part of the LHSC Shared Governance Model London Health Sciences Centre Vanessa Burkoski, RN,, PhD [email protected] PF20: Leveraging Technology to Improve Patient Engagement Department of Veterans Affairs Gerald Showecker [email protected] PF21: Lung Biopsy—Reduction in Procedure Start Times North Shore Medical Center Miriam Neuman, MD [email protected] PF23: Northern Parterns in Care— Improving Access to Quality Care in Rural and Remote Communities University of Northern British Columbia Tammy Klassen-Ross [email protected] PF29: Preventing Admissions & Readmissions: Providing Health Care Outcomes not Health Care Services Datix Daniel Cohen, MD [email protected] PF30: Quality of Life in Patients with Heart Failure Measured by the Kansas City Cardiomyopathy Questionnaire Monmouth Medical Center Sharon Holden [email protected] PF31: Reduce Time Taken for Discharged Inpatient to Receive Final Bill JurongHealth Clay Kian Loong Goh [email protected] PF32: Team Care for Chronic Disease Patients: Using Lay “Care Guides” Allina Health System Kim Radel [email protected] PF33: The Patient Structured Day London Health Sciences Centre Elizabeth Runciman, RN [email protected] PF34: Univeristy of Florida Health Physicians Patient Access Center Default User Profile Organization Kelly Kerr [email protected] Triple Aim for Populations TA1: 5 Feet in 5 Seconds: An Application of Lean Visual Management BIDMC Michelle Sheppard, RN [email protected] STORYBOARDS PS112: Understanding the Value of Library and Information Services in Patient Care London Health Sciences Centre Karla Van Kessel [email protected] TA2: A Collaborative Outreach Initiative to Improve Colorectal Cancer Screening Beth Israel Deaconess Medical Center Scot B. Sternberg [email protected] TA3: ACMS Stable Patient Extended INR Protocol as a Model for Implementing Clinical Guidelines Beth Israel Deaconess Medical Center Jennifer E Mackey, PharmD [email protected] TA4: Analysis of No Shows Among Allergic Rhinitis Patients at the Khoo Teck Puat Hospital Khoo Teck Puat Hospital Alex Mathews RPh [email protected] TA5: Boston to Orlando: IHI’s Annual Walking Challenge Institute for Healthcare Improvement Kelcey Heman [email protected] TA6: Breaking Traditions: Integrating Triage and Fast Track to Improve Patient Experience in the Emergency Department MidState Medical Center Megan Heidenis, RN [email protected] TA7: Change by Design: A New Paradigm for Primary Care Mayo Clinic Douglas Wood, MD [email protected] TA8: CMS Requirements for Cancer Reporting University of Texas, MD Anderson Cancer Center Lisa Kidin, RN [email protected] TA9: Creating a Diabetes Group Visit For Brazilian Diabetic Patients Cambridge Health Alliance Monica Demasi, MD [email protected] Which storyboard did you enjoy? Tweet it using #IHI25Forum 55 STORYBOARDs Storyboard Reception Tuesday, December 10, 4:30 PM – 6:30 PM, Palms Ballroom During this reception, presenters will be standing by their boards to answer questions. TA10: Decreased Surgical Ligation of the Patent Ductus Arteriosus Following Implementation of Conservative Clinical Guidelines Nationwide Children’s Hospital James Dail [email protected] TA11: Driving Quality Initiatives to Improve the Life of Every Person with Kidney Disease Ontario Renal Network Graham Woodward Graham.Woodward@renalnetwork. on.ca TA12: Early Years Collaborative in Scotland: The Best Place in the World to Grow Up! Scottish Government Rosamund Gray, RN [email protected] TA13: Effects of the Critical Care Outreach Team on Bone Marrow Transplantation Ward Survival Sao Camilo Claudia Jorge, MD [email protected] TA14: Emergency Medical Pediatric Program (EMP): Timely Access to Specialized Paediatric Care Windsor Regional Hospital Kelly Bartnik, RN [email protected] TA15: Frail Elderly Predictive Care Model Mercy Hospital Linda Horton, RN [email protected] TA16: Healthy Heart—Healthy Mind London Health Sciences Centre Kamini Vasudev, MD [email protected] TA17: Implementation of a Critical Care Outreach Team on Bone Marrow Transplantation Ward Sao Camilo Claudia Jorge, MD [email protected] TA18: Improving HEDIS Quality Performance Through Cost-Effective Technology and Enhanced Patient Engagement Kaiser Permanente Karen Clark [email protected] TA19: Improving Patient Access and Experience Through Deployment of Advanced Access Scheduling MultiCare Health System Ashley Keays DO [email protected] 56 TA20: Improving Performance in Practice (IPIP) Advances State-Based Primary Care American Board of Medical Specialties Sigita Wolfe [email protected] TA21: Increased Screening for Proteinuria in Chronic Kidney Disease Using Education and Reminders Louis Stokes VA Medical Center Jeffrey Beamish, MD, PhD [email protected] TA22: It’s COOL To Be COOL Methodist West Houston Hospital Marcia Ozdenvar [email protected] TA23: Jump Start Your Heart: A New Cardiac Program Methodist West Houston Hospital Laura Espinosa, RN, PhD [email protected] TA24: Optimizing Value Streams for Breast Cancer Patients to Receive Supportive Services Using Lean Methodology University of North Carolina (UNC) Health System Kinley Taylor [email protected] TA25: Pneumonia Antibiotic Guidelines Variations in Oncology University of Texas, MD Anderson Cancer Center Lisa Kidin, RN [email protected] TA26: Primary Care Integration Project and Evaluation University Health Network Kaitlin Pattrick [email protected] TA27: Reducing Heart Failure Readmissions: The CT Experience John Dempsey Hospital Wendy Martinson, RN [email protected] TA30: Simplifying Simple Appendicitis: Same Day Discharge after Appendectomy Nationwide Children’s Hospital Kelli Kurtovic [email protected] TA31: Staff Experience and Healthy Work Environment (HWE): A Nursing Resource Team (NRT) Perspective Western University Lisa Ducharme [email protected] TA32: Surveying the Potential Needs of Patients Attending Psychological Services in a New Clinical Area London Health Sciences Centre Felicia Otchet [email protected] TA33: The Impact on Patients of Psychological Services Moving to a New Clinical Area London Health Sciences Centre Andrea Lazosky, PhD [email protected] TA34: The Nurse Practitioner Role in a Comprehensive Pain Management Program London Health Sciences Centre Charlotte McCallum, RN [email protected] TA35: The Triple Aim and Outreach to Long-term Care Patients Mayo Clinic Dawn Francis [email protected] TA36: The Underreported Pre-Diabetic Patient’s Identifying Patients At-Risk for Diabetes In Order to Improve Outcomes Esse Health Carla Beckerle, RN [email protected] TA37: Tobacco Treatment for Two: Connecting Pregnant Smokers with Evidence-Based Cessation Resources Dartmouth-Hitchcock Concord Hilary K. Alvarez, MD [email protected] TA38: Workplace Violence in the Emergency Department: Giving Staff the Tools and Support to Report Mayo Clinic Erin Larson, RN [email protected] TA28: Reducing Non-Emergent Use of the ER and Decreasing Total Cost of Care using Collaboration HealthPartners Kelly Logue MA [email protected] TA29: Reducing Staff Injuries on a Specialty Unit for Patients with Developmental Disabilities Cincinnati Children’s Hospital Medical Center Davona Tucker [email protected] 25th Annual National Forum on Quality Improvement in Health Care Student Storyboards Following is a list of all student storyboards submitted before November 13th. Please walk through the Student section in Cypress 1 to see these below and even more student storyboard projects. S1: A Trinity of Engagment Transforms Care at UPMC Shadyside’s 6 Main UPMC Shadyside Irma D’Antonio [email protected] S2: ABC Patient Safety Hospital General 450 Hospital General 450 Verónica Quiroga [email protected] S3: An Interprofessional Student Health Care Collective Yale School of Medicine Phoebe Kuo [email protected] S4: Cardiff Medics’ Student-Patient Chapter: 2013 Cardiff University Hope Olivia Ward [email protected] S5: CLABSI: The Path to Zero Tulane University School of Medicine John Bates [email protected] S6: Consultation Services: A Gateway to Patient Safety Tulane University School of Medicine Mingyang Liu [email protected] S7: Creating a Health Care Improvement Curriculum Baylor College of Medicine Mitchell Peterson, Ann Chou, Nathan Law, Matthew Rees [email protected] S8: Decreasing Wait Time for Suboxone Patients Harvard School of Public Health, The Dimock Center Jonathan Lichkus [email protected] S9: Developing a Revised Organ Verification Protocol Tulane University School of Medicine Alexandra Dixon [email protected] S10: Dose Optimisation of Pregabalin Prescribing to Improve Cost Effectiveness in a Primary Care Setting Imperial College London Kavita Aggarwal [email protected] S11: Eliminating PICU Consults Transformed the Role of Medical Response Teams at Cincincinnati Children’s Medical Center University of Cincinnati College of Medicine Ravi Grandhi [email protected] S13: Formation of a Combined New Orleans IHI Open School Chapter Tulane University School of Medicine Ryan O’Holloran [email protected] S14: Georgetown University IHI Open School Chapter Georgetown University Beth Shields [email protected] S15: Hospital Elder Life Program Education to Prevent Delirium at an Acute Care Hospital London Health Sciences Centre Barbra Watson [email protected] S16: How do Hospitals Work? A Patient’s Orientation Tulane University School of Medicine Adrienne Krebs [email protected] S17: How Low is Too Low? A Quality Improvement Project about the Overtreatment of Diabetes Mellitus in the Elderly Louis Stokes VA Medical Center Tania Jaber [email protected] S18: Impact of Quarterly Interdisciplinary Medication Reviews on Resident Care in a Canadian Long-Term Care Facility University of Waterloo Linda Zhao [email protected] S19: Implementation and Evaluation of a Practice Guideline for the Management of Respiratory Distress Syndrome in Preterm Infants: A Quality Improvement Initiative Athabasca University/ London Health Sciences Centre Brooke Read [email protected] S20: Implementation of a Nurse-Driven Foley Catheter Removal Protocol New Orleasns Healthcare Improvement Group Andrew Wickerham [email protected] S21: Implementing a Revised Organ Verification Protocol Tulane University School of Medicine Tim Lindsay [email protected] S22: Implementing Lean to Reduce Appointment Length University of Michigan Medical School Bess Connors [email protected] S23: Implementing the Strong for Surgery Checklist University of Washington Catherine Kling [email protected] S24: Improvement of Hand Hygiene in the Post-Anesthesia Care Unit University of Illinois at Chicago John Iskander [email protected] S37: QuIPS: A Student-Led Conference Success Story University of Toronto Sabrina Kun Tang [email protected] S44: Test of a Family-Centered Discharge Tool Portland State University Emily Henke [email protected] S25: Improving the Assessment of Febrile Children in Primary Care: Small Steps to a Big Change Cardiff University Beth Mclldowie [email protected] S38: Reducing Musculoskeletal Pain-Related Nonurgent ED Visits Cleveland VA Medical Center Mary Angelynne Esquivel [email protected] S45: The Development and Growth of the PSU & OHSU IHI Open School Chapter Portland State University Cassandra Dictus [email protected] STORYBOARDS S12: Empowering Students Through Interprofessional Education, Leadership to Promote Health Care Improvement & Patient Safety The University of Oklahoma Health Sciences Center Lin Goldston [email protected] S26: Improving the Care of Stroke Survivors in Wales, UK Cardiff University Hope Olivia Ward [email protected] S39: Remote Screening for Diabetic Retinopathy Using Non-Mydriatic Camera Kaiser Permanente Manjula G Vaghjiani [email protected] S27: Instituto Nacional de Enfermedades Respiratorias Instituto Nacional de Enfermedades Respiratorias Nelson Rodrigo Cruz Castellanos [email protected] S40: Student Experience: Systems Design for Non-Medical Student Placements Western University Kelly Ainge [email protected] S47: Under Siege: The Bed Management Battle Galway Roscommon University Hospitals Marese Murphy [email protected] S28: Investigating Primary Care Incident Reporting Cardiff University Amy Butlin [email protected] S41: Studying the Impact of Choosing Wisely Campaign Rutgers University Santosh Bhaskarabhatla [email protected] S48: University of Cincinnati IHI Open School Chapter University of Cincinnati Elizabeth Hathaway [email protected] S29: Longitudinal Family Medicine Improvement Curricula Oregon Health and Science University and Portland State University Bridget Lynch, MD [email protected] S42: Surgical Safety Checklist Implementation Tulane University School of Medicine Ryan O’Holloran [email protected] S49: “What Can I Do to Improve Your Stay Today?”—Interprofessional Health Care Students Improving Patient Care at the Bedside Cardiff University Hope Olivia Ward [email protected] S30: Morbidity and Mortality Conference Dedicated to Quality Improvement Huntington Memorial Hospital Gabriella Pearlman [email protected] S31: N4CAST: A Nursing Staff Forecasting and Planning Tool London Health Sciences Centre / University of Toronto Jennifer Yoon [email protected] S32: OHSU Newborn HepB Immunization Improvement Campaign Oregon Health and Science University/ Portland State University Brandon Lynch [email protected] S43: Taking Time to Care for Ourselves: A Breast Cancer Awareness Event Bellin College Hannah Jochman [email protected] S46: The Quality Improvement Learners Team (QILT) Portland State University Kelsey Priest [email protected] Highlighted storyboards are those that will be presented during a Storyboard Walkaround A, B, C, D, or E session. S33: Patient Empowerment Impact on Surgical Safety Checklist Compliance Tulane University Hospital and Clinics Elizabeth Wingo [email protected] S34: Preparing Students for Residency—Simulation Bootcamp University of South Dakota Rebekka Sneed [email protected] S35: Quality Improvement at a Student-Run Free Clinic Tulane University School of Medicine Mingyang Liu [email protected] S36: Quality’s Sustainable Development Contest: The Triad that Leads Health Care Improvement Universidad del Valle de México Uribe Pacheco Rodrigo [email protected] 57 PRESENTER Index A Adams, Laura................................ L15 Anand, Shikha............................... L11 Angel, Clay............................ A17, B17 Crocker, Liz....................................C18 Crowe, Ginna........................ L25, M11 Cummings, Ormella..................... VSV9 Curtis, Kevin..........................D13, E13 B Baker, Neil............................ A10, B10 Balestracci, Davis............................ M7 Balik, Barbara.........L23, M1, A21, B21 Banerjee, Jay.........................D14, E14 Barrington, Monica........................C24 Barton, Kelly................................ VSV8 Batalden, Paul............................... L10 Belkin, Gary...................................C12 Bell, Donna................................... M19 Bell-Polson, Deb............................ FE3 Benjamin, Evan.......................M2, C19 Bennet, Jennifer............................RFE Bennett, Karen............................... L21 Bennett, Brandon......................... M19 Benneyan, James........................... M5 Bernard, Peter.............................. RFB Berry, Leonard.............. A12, B12, FE7 Berwick, Donald..........M9, C22, E1, K4 Betancourt, Joseph........................ L26 Bevan, Helen............... M10, A16, B16 Bhaskarabhatla, S.........................SWC Bieling, Peter........................ A25, B25 Bihrle Johnson, Marian.................. FE5 Bintz, Marilu................................ VSV8 Bisognano, Maureen........................K1 Bitton, Asaf.................................... L20 Boehler, Rich.................................C10 Bones, Kate................................... FE4 Bosch, Sheila...................................C8 Boudreau, Karen........................... M15 Boulton, John.................................. L7 Bourn, Scott...........................D20, E20 Boyd, Larry.................................. VSV9 Brooks, Kristen..................... A17, B17 Brooks, Kathryn.................... A20, B20 Brownlee, Shannon..........................A1 Brummel-Smith, Ken.................... M18 Butts, Sue..................................... M11 D Dagi, T Forcht........................D21, E21 Dalton, David................................. L30 D’Angelo, John.......................D24, E24 Davidoff, Frank.............................. L10 Davies, Louise................................ L10 Davies, Mik....................................RFA Davis, Haidee...................... B1, D6, E6 Davis, Nancy................................. RFD Deao, Craig................................D7, E7 DeBartolo, Kate..............L12, A13, B13 Deen, Jana................................... M22 Delbanco, Tom.................................C1 Deremo, Dorothy........................... M18 Dickson, Eric.................................. FE6 Digioia, Anthony....... A4, B4, C23, D17 . ..................................................... E17 Diller, Thomas....................... A26, B26 Dilling, James.............................. VSV7 Doerfler, Martin......................D24, E24 Dolin, Jordan................................ RFD Dorney Koppel, Grace Anne...........C15 Downes, Tom........................ L14, M13 Duncan, Kathy.......................FE3, A13. ............................................ B13, C23 DuPree, Erin................................... M9 C Calderon, Alvin............................... L28 Carpenter, Christopher...........D14, E14 Carter, Randall...................... A21, B21 Chafetz, Lynne................................ M4 Chase, Alide.................VSV3, D18, E18 Chassin, Mark................................. M9 Cherouny, Peter............................. L25 Chow, Marilyn................. C4, D11, E11 Christensen, Mylia......................D4, E4 Classen, David.......................... A3, B3 Clemmer, Terry.............................. M24 Cochran, John............................. VSV3 Cohen, Gary..................................... E1 Cohen, Sandy (Alexander).............. L16 Coleman, Eric............................... M17 Colletti, Richard............................. L17 Compton-Phillips, Amy...........D12, E12 Connors, B....................................SWD Constantine, Roy....................D21, E21 Conway, William........................... VSV5 Cooper, Andrew............................. L18 Coye, Molly................................... RFB Crandall, Wallace........................... L17 Crane, Joseph................L13, A18, B18 Crisp, Nigel............................. B1, C12 58 E Eby, Doug............................... L3, M20 Ely, E Wesley................................. M24 F Fahy, Patricia...................................C7 Fairman, Steve...................... A16, B16 Federico, Frank....... L29, A24, B24, C5 . .............................................D22, E22 Feeley, Derek.........................D25, E25 Ferrans, Richard........................... RFD Ferrigno, Rock...........................D8, E8 Fisher, Michael............................ VSV6 Fitzgerald, Elaine............................ L11 France, LeLayna..............................C8 Frankel, Allan................................ M21 Fraser, Sarah................................ M14 Fredriks, Dean.......................D11, E11 G Galli, Brian J................................. RFD Gandhi, Tejal.................................. L27 Gelmon, Sherril..........................D4, E4 Genzer, Kristie........................D16, E16 Geraghty, Barbara..................D26, E26 Gerhard, Carrie..................... A14, B14 Glisson, Rachael............................C17 Godfrey, Marjorie............................ L14 Gottlieb, Katherine........................ M20 Gould, Bernice.......................D15, E15 Grandhi, Ravi................SWA, D19, E19 Grange, Christina...........................C17 Gray, Rosamund...................M19, RFE Greene, Hugh........................... A8, B8 Griffin, Fran................................... FE2 Grogan, Mary Ellen………….D26, E26 Gruner, Dean.............................D5, E5 Guenther, Robin............................... E1 Gunther-Murphy, Christina.....FE6, A13. ............................................ B13, C20 Gustafson, David................... A19, B19 Guy, Matthew.................................RFE H Haas, Derek...............................D3, E3 Haerkens, Marck...........................C25 Hamnett, Paul............................... RFD Hanley, Bill......................................C2 Hannenberg, Alexander.........D21, E21 Hanson, Daniel.............................. L28 Haraden, Carol........................ L27, M8 Hart, Robert...........................D16, E16 Haskell, Helen.......................D18, E18 Hatoun, Jonathan..................D19, E19 Hayward, Martha...........L23, A21, B21 .............................................D18, E18 Healy, Maureen......................D26, E26 Henriks, Goran.......L5, VSV1, M14, B1, . .............................................D12, E12 Hiltonen, Beth..................................C8 Homer, Charles.............................. L11 Horowitz, Leora............................. .L19 Hunt, Jacquelyn............................. L15 J Jack, Brian.................................... L19 Jacobsen, Diane....................D24, E24 James, Brent........................... M5, M9 Jarman, Brian................................C22 Jarrett, Mark.................................... L8 Jensen, Kirk...................L13, A18, B18 Jervis, Ramiro................................C14 Johnson, Cheri............................... L25 Jordan, Victoria............................... M5 K Kabcenell, Andrea................... L22, M1 Kanter, Michael......................D27, E27 Kantrowitz, Michael................D19, E19 Kaplan, Gary................................. M16 Kenney, Linda............................... M22 Kershaw, Sean.................................C2 Kerwin, George............ L18, VSV2, C13 Kinkead, Laura................................ M6 Kirby, Thornton..................... A26, B26 Knox, Peter.......................... L18, VSV2 Knudson, Susan.............................C16 Kotagal, Uma......................... L2, VSV6 Kramer, Stacy................................RFE Krause, Jean......................... A14, B14 Krause, Christina............................. M3 Krueger, John..................................C9 L Labinjoh, Catherine............... A22, B22 Lachman, Peter...................... L9, M23 Laderman, Mara........................... M15 Laing, Shirley................................ M19 Leavitt Gullo, Sue................... L25, FE1 Leitch, Jason.... L9, M19, B1, D25, E25 Leiterman, Gretchen..................D2, E2 Lenarz, Loie (Lois)........................... M6 Leonard, Michael.......................... M21 Levy, Paul......................FE4, D19, E19 Lewis, Ninon.................L12, M19, RFE Lichkus, J.....................................SWB Litvak, Eugene................................. L9 Liu, Michael...............................D3, E3 Lloyd, Robert...........L5, FE2, A15, B15 Loehrer, Saranya............................ FE1 25th Annual National Forum on Quality Improvement in Health Care Longmate, Andrew............... A22, B22, .............................................D12, E12 Lown, Beth....................................C18 Luther, Katharine.............L2, A15, B15 .................................................D3, E3 Lynn, Joanne................................ M18 M MacKenzie, Simon........................... L7 Madigosky, Wendy.................... A9, B9 Madsen, Victoria................... A25, B25 Magnan, Sanne................................C2 Maher, Lynne................................... L6 Mahoney, Mary................................ L8 Makoul, Gregory.....................D13, E13 Mann, Sharon..................................C6 Margolis, Peter..................... L17, VSV6 Mate, Kedar........................M8, D6, E6 Mayer, David..........................D19, E19 McCannon, Jessica........................ L24 McCannon, Joe.......................M8, RFA McCarthy, Chris............................... L6 McCracken, Kris............................ L26 McCutcheon Adams, Kelly.... L24, M24 . .................................... C20, D10, E10 McIlwain, Thomas......................... M13 Meaker, Rob............................. A2, B2 Memoracion, Elena................... A7, B7 Merrithew, Nicole.......................D4, E4 Micalizzi, Dale Ann........................ M23 Moen, Ronald................................C11 Mondoa, Catherine................ A22, B22 Moon, Tania................................... L17 Moriarty, Katie............................D2, E2 Morrison, Kristin.....................D19, E19 Moses, James................... FE5, A9, B9 Munch, David............................... M12 Murray, Sandra................L4, A11, B11 .............................................D10, E10 N Nicolaou, Lisa................................ L21 Nielsen, Gail......................... L19, M17 Niemann, Jason.................... A24, B24 Nohr Beck, Lindsay..........................K3 Nolan, Kevin......................... A18, B18 Norouzzadeh, Shaghayegh............... L1 O Ogrinc, Greg.................................. L10 O’Leary, Dennis................................C4 Orlikoff, Jamie................................. M2 O’Shaughnessy, Patrick................... M9 Ovretveit, John.................................C3 P Pabo, Erika.................................... L20 Parmentier, Darlene...............D24, E24 Parry, Gareth.................................. L16 Parsons, Tamera............. VSV9, A6, B6 Peden, Carol.................................. L29 Penner, Josef........................ A11, B11 Perla, Rocco.................................... L4 Peterson, Kathleen.........................C26 Phillips, Jennifer.......................M4, C6 Pinto, Carlos..................................C26 Plsek, Paul...................................... M4 Poku, Asantewaa...........................C14 Posencheg, Michael.......................C11 Power, Maxine...............L30, D23, E23 Priest, K........................................ SWE R Raj, Prince.................................D8, E8 Ramsay, Rebecca..........L22, A20, B20 Ray, Deborah.................................C11 Reid, Amy...................................... L16 Reiss-Brennan, Brenda................. M15 Richmond, Mike................. B1, D6, E6 Roberts, Christopher................. A2, B2 Robson, Brian................................ L15 Romagnoli, James............................ L8 Ruelas, Enrique.........................D6, E6 Rukat, Agata................................ VSV1 Rutherford, Patricia............... L19, M17 Ryckman, Frederick..................... VSV6 S Sadler, Blair............................ M22, E1 Saeed, Shahab.................................D1 Saini, Vikas......................................A1 Sands, Kenneth.............................C19 Santrach, Paula........................... VSV7 Sayers, Diane................................. L21 Scanlon, Kerri Anne.................. A7, B7 Scanlon, Matt................................ M23 Schall, Marie.......... M8, RFA, D10, E10 Schaub, Diane.......................... A5, B5 Schellekens, Wim.................... B1, C25 Schilling, Lisa.............. L2, RFA, D3, E3 Schraeder, Lisa......................D17, E17 Schreiber, Michelle...................... VSV5 Scott, Michael....................... A24, B24 Scott, Carolyn............................ A6, B6 Scoville, Richard..................L1, D9, E9 Seguin, Cara.................................. L21 Selberg, Jeffrey..............................C22 Sevin, Cory..................................... L20 Shabot, M. Michael...................... VSV4 Shewale, Jitesh......................... A5, B5 Silversin, Jack............................... M16 Skootsky, Samuel.......................... RFB Smith, Coleen....................... A26, B26 Smith, Kristofer..............................C14 Smith, Andrea........................D27, E27 Smith, Kevin................................... M3 Snyderman, Nancy..........................K3 Sodzi-Tettey, Felix K. Sodzi...............B1 Solazzo, Mark.................................. L8 Spear, Steven................................ M13 Spuhler, Vicki................................ M24 Staines, Anthony............................ L29 Stearns, Myra.................................C15 Steinfield, Rebecca........................ L20 Stevens, David............................... L10 Stewart, Kevin............................... M22 Stiefel, Matthew.............................C16 Sugarman, Jonathan...................... L20 Swanson, Julia............................. VSV5 Swensen, Stephen......................... FE7 T Taigman, Mike.......................D20, E20 Taitz, Jonny................................... M23 Tan-Mcgrory, Aswita....................... L26 Taylor, Jane................................... M11 Terris, Darcey.................................C17 Thompson, Jeff................................ E1 Thompson, Ken............................ M14 Tierney, Steve................................... L3 Toussaint, John......... A12, B12, D5, E5 Troyer, Drew.....................................C9 Tufano, Amy................................... M4 V Van Der Hoeven, Johannes G.........C25 Van Straten, Randy........................C13 Varnam, Robert............................. M10 Vyas, Dimple..................................C21 W Wagner, Robin...............................C27 Walker, Jan......................................C1 Warren, Abigail......................D23, E23 Warshaw, Harriet............................ L24 Webster, Patty................................ L12 Weihenmayer, Erik...........................K2 Weingarten, Scott...................... A3, B3 Weiss, Kevin..................................C27 Wen, Leana........................... A23, B23 White, Maureen........................ A7, B7 White, Lynn............................D20, E20 White, Kristine................................ L23 Whittington, John................... L22, C21 Williams, David............ M12, A15, B15 .............................................D20, E20 Willson, Alan.................................. L18 Woebbeking, Laura....................... RFD Wolfson, Daniel................................A1 Wolterman, Dan........................... VSV4 Wong, Winston.......................D15, E15 Worden-Kirouac, Elisa......................C8 Wozney, Bradley........................... RFB Wright, Jean...................................C15 Y Yates, Gary................................M9, C5 Yokoe, Deborah..............................C23 PRESENTER INDEX Provost, Lloyd..................L4, A11, B11 Pugh, Michael................................. M1 Puri, Ajay........................................ M3 Z Zak, Helen....................................... L1 59 Exhibitors Acesis Booth #1424 2047 Old Middlefield Way Mountain View, CA 94043 650-954-6410 [email protected] www.acesis.com Acesis is a cloud based platform that manages patient safety oversight and organizational compliance. The system is optimized to ease date capture, enable consistent workflow, and support robust analytics. Gold Sponsor Solutions Booth #113 Agency for Healthcare Research & Quality Booth #1438 540 Gaither Rd Rockville, MD 20850 301-427-1364 [email protected] www.ahrq.gov Within the Department of Health and Human Services, AHRQ is charged with improving the quality, safety, efficiency, and effectiveness of health care for all Americans. AHRQ supports research to improve the quality of health care and promote evidence based-decisions. Aging with Dignity Booth #212 ACP - American College of Physicians Booth #1212 190 N. Independence Mall West Philadelphia, PA 19106 800-523-1546 [email protected] www.acponline.org The American College of Physicians (ACP) is the world’s largest medical specialty society with the attention of more than 100,000 internists. Resources for recruiters include: Annals of Internal Medicine, ACP Hospitalist, ACP Internist, and ACP Online (the website for internal medicine, www.acponline.org). Advanced Practice Strategies Booth #713 New Exhibitor 470 Atlantic Ave, 14th Floor Boston, MA 02210 617-275-7300 [email protected] www.aps-web.com Advanced Practice Strategies accelerates high reliability in health care delivery by measuring and improving clinical knowledge and judgment. PO BOX 1661 Tallahassee, FL 32302 888-594-7437 [email protected] www.agingwithdignity.org National nonprofit organization: Created the Five Wishes advance directives used by 35,000 organizations including hospices. Available in 27 languages and Braille. New online resources, adolescent/young adult, and pediatric versions. American Academy on Communication in Healthcare Booth #1016 201 E. Main St., Suite 1405 Lexington KY 40507 859-514-9199 [email protected] www.AACHonline.org The American Academy on Communication in Healthcare (AACH), a non-profit organization, provides support for education and research to improve communication outcomes among clinicians and across health care teams and systems. American Heart Association Booth #102 7272 Greenville Ave Dallas, TX 75231 800-242-8721 www.heart.org The American Heart Association and American Stroke Association offer a complete portfolio of quality improvement programs dedicated to bettering patient outcomes through guideline adherence. The programs include offerings in heart failure, stroke, and more. 8301 Excelsior Drive Madison, WI 53717 888-830-2644 [email protected] www.amphionmedical.com Amphion is a premier provider of technology-driven transcription, coding, and core measures services. Whether you need a technology platform or outsourcing services, Amphion can help. Avatar Solutions Booth #112 New Exhibitor 1000 Primera Blvd Ste. 3144 Lake Mary, FL 32746 USA 800-AVATAR4 (282-8274) [email protected] www.avatarsolutions.com Avatar Solutions is an innovative survey, data measurement, and performance improvement company with over 30 years of experience. We specialize in Patient, CAHPS, Employee, and Physician Surveys. Baldrige Performance Excellence Program Booth #415 100 Bureau Drive Stop 1020 Gaithersburg, MD 20899-1020 301-975-2036 [email protected] www.nist.gov/baldrige The Baldrige Program promotes organizational excellence through assessment, feedback, and best practice sharing. The program develops/disseminates the Criteria for Performance Excellence and manages the Malcolm Baldrige National Quality Award. BMJ Booth #1106 1685 South Colorado Blvd, Suite S-271 Denver, CO 80222-4040 855-458-0579 [email protected] company.bmj.com BMJ provides access to the best knowledge and improvement tools essential for delivering quality healthcare. These are applied in cases ranging from treating a patient to allocating finite resource. Amphion Medical 60 25th Annual National Forum on Quality Improvement in Health Care Board of Pharmacy Specialties Booth #915 New Exhibitor 2215 Constitution Avenue NW Washington, DC 20037 202-429-7542 [email protected] www.bpsweb.org The Board of Pharmacy Specialties (BPS) is an autonomous Division of the American Pharmacists Association (APhA), founded in January 1976 to recognize specialties and certify pharmacists in specialized areas of pharmacy practice. Six specialties are currently recognized by BPS, including: 1) nuclear pharmacy, since 1978; 2) nutrition support pharmacy, since 1988; 3) pharmacotherapy, since 1988; 4) psychiatric pharmacy, since 1992; and 5) oncology pharmacy, since 1996. 6) ambulatory care pharmacy, since 2011. More than 15,800 pharmacist specialists are currently certified by BPS. Care COPILOT™ by Allina Health Booth #516 New Exhibitor 2925 Chicago Avenue Minneapolis, MN 55407 612-262-5056 [email protected] www.healthcarecopilot.com Care COPILOT reflects research from Allina Health and the University of Minnesota. Aimed at optimal management of chronic illnesses, Care COPILOT disseminates the Care Guide Model to health care organizations nationwide. Care Team Connect Booth #1418 518 Davis St Ste 230 Evanston, IL 60201 877-736-4631 [email protected] www.careteamconnect.com Care Team Connect’s integrated care management platform powers innovative population health strategies. Our secure, web-based platform enables creation of shared patient-centric care plans to power cross continuum coordination and collaboration. CECity.com, Inc. Cerner Corporation Columbia HeartSource Booth #407 Booth #1101 Booth #817 285 Waterfront Drive East, Suite 100 Homestead, PA 15120 412-338-0366 [email protected] www.cecity.com CECity.com, Inc. is the leading provider of cloud-based quality reporting, performance improvement, and lifelong learning platforms. Center to Advance Palliative Care Booth #209 1255 Fifth Avenue, Suite C2 New York, NY 10029 212-201-2670 [email protected] www.capc.org The Center to Advance Palliative Care (CAPC) provides health care professionals with the tools, training, and technical assistance necessary to start and sustain successful palliative care programs in hospitals and other health care settings. Platinum Sponsor Booth #1112 New Exhibitor 100 Centurion Way Williamston, MI 48895 800-248-4058 [email protected] www.centurionmp.com Centurion develops unique products with critical input from clinicians. Featuring the CVC Zone Bundle – a central line insertion bundle with everything you need to help prevent CLABSIs and improve outcomes. Monday, December 9 3:30 PM – 6:30 PM 2800 Rockcreek Pkwy Kansas City, MO 64117 816-221-1024 [email protected] www.cerner.com 21 Audubon Avenue, 2nd Floor, Room 209 New York, NY 10032 212-305-9317 [email protected] www.columbiaheartsource.org Cerner is contributing to the systemic change of health and care delivery. For more than 30 years, Cerner has been executing its vision to make health care safer and more efficient. Cerner is building on the knowledge that is in the system to support evidence-based clinical decisions, prevent medical errors, and empower patients in their care. Columbia HeartSource is a management services group at Columbia University Medical Center. We customize solutions to enhance cardiovascular programs and help our affiliates to succeed and grow in an ever-evolving health care environment. Chameleon Corporation Booth #106 10:30 AM – 1:30 PM Booth #100 633 N Saint Claire St. Chicago, IL 60611 312-202-5085 [email protected] www.facs.org/cancer 1:00 PM: Forum Fortune Drawing 625 Bakers Bridge Suite 105 Franklin, TN 37067 615-656-3280 [email protected] www.chameleonwhiteboard.com Chameleon, the world’s first interchangeable whiteboard, provides an entirely erasable surface (no staining, shadowing or ghosting) while providing for cost effective content/language changes through the use of interchangeable inserts. CHG Hospital Beds Booth #1201 1020 Adelaide St South London, ON N6E1R6 519-963-4010 [email protected] www.chgbeds.com CHG is the leader in low beds. To optimize patient safety, “Select” features a 10” low height, scale, multi-zone bed exit alarm, open architecture, antibacterial rails/boards, and more. CipherHealth Commission on Cancer For more than a century, the American College of Surgeons has focused on quality patient care. Through the Commission on Cancer Accreditation Program, providers demonstrate their commitment to providing high-quality patient care. Commonwealth Fund Booth #413 1 East 75th Street New York, NY 10021 212-606-3800 [email protected] www.commonwealthfund.org The mission of The Commonwealth Fund is to promote a high performing health care system that achieves better access, improved quality, and greater efficiency, particularly for society’s most vulnerable. Gold Sponsor Booth #814 New Exhibitor 555 8th Avenue New York, NY 10018 617-820-4241 [email protected] www.cipherhealth.com CipherHealth provides care continuity solutions that improve hospital efficiency and patient satisfaction. Our post-discharge communication platform helps hospitals reduce preventable readmissions and increase HCAHPS while ensuring resources are utilized effectively. Conifer Health Solutions Booth #1200 2401 Internet Blvd. Suite 201 Frisco, TX 75034 877-CONIFER [email protected] www.coniferhealth.com Everything we do at Conifer Health Solutions is rooted in our commitment to transforming health care by enhancing the patient experience, supporting financial improvement, and driving value-based performance. Welcome Reception 4:30 PM – 6:30 PM Tuesday, December 10 9:30 AM – 10:30 AM (By appointment only) 10:30 AM – 1:30 PM 4:15 PM – 6:30 PM Storyboard Reception 4:30 PM – 6:30 PM Wednesday, December 11 Cooper Signage & Graphics Booth # 217 New Product Release 2405 Lance Court Loganville , GA 30052 770-736-1522 [email protected] www.wayfindingforhealthcare.com CS&G is recognized as the preeminent leader in designing and providing wayfinding systems for health care facilities. CS&G’s wayfinding services and products have been awarded the exclusive endorsement of the AHA. EXHIBITORS Centurion Medical Products New Exhibitor New Exhibitor Exhibit Hall Hours Courtemanche & Associates Booth #908 4475 Morris Park Drive, Suite B Charlotte, NC 28227 704-573-4535 [email protected] www.courtemanche-assocs.com Courtemanche & Associates is a nationally recognized health care consulting firm specializing in regulatory and accreditation, leadership development, quality and safety improvement, and ongoing support for health care leaders, administrators, and practitioners. Which exhibit booths did you visit? Tweet it using #IHI25Forum 61 Exhibitors Creative Healthcare Gold Sponsor Gold Sponsor CHC provides tools and training to support efforts in health care improvement. We train and certify in Lean, Six Sigma and also ISO - deployment. Online and onsite training options available. Crimson, A Division of The Advisory Board Company Booth #601 2445 M St NW Washington, DC 20037 202-266-6639 [email protected] www.advisory.com/crimson A national technology-based collaborative designed to support providers in the migration towards value-based care. Currently supporting 1200+ hospitals, 20+ clinically integrated networks and 400K+ physician cost and quality profiles. Dartmouth College—Master of Health Care Delivery Science Program Booth #522 37 Dewey Field Rd Ste. 200 HB 7253 Hanover, NH 03755 603-646-1222 [email protected] www.mhcds.dartmouth.edu Designed for accomplished working professionals, Dartmouth’s 18-month Master of Health Care Delivery Science program equips students with new skills and knowledge to lead the vital transformations taking place in health care today. Datix (USA) Inc Booth #206 155 North Wacker Drive Suite 4250 Chicago, IL 60606 312-803-4991 [email protected] www.datixusa.com Patient safety and risk management software to spot trends as events occur, reduce future harm by prioritizing risks and creating corrective actions. Integrated reporting and configurable dashboards capture real time information. Over 20 years proven experience in health care settings worldwide. 62 DNV Healthcare Inc. Booth #513 DebMed LLC Booth #1107 2815 Coliseum Centre Drive, Suite 600 Charlotte, NC 28217 704-357-4258 [email protected] www.debmed.com The DebMed® Group Monitoring System (GMS™) is the world’s first electronic hand hygiene monitoring system developed from proven scientific research. It tracks not just how many times staff cleaned their hands, but how many times they should have cleaned their hands, based on the World Health Organization’s Five Moments for Hand Hygiene. 400 Techne Center Dr. Suite 100 Milford, OH 45150 281-685-9996 [email protected] www.dnvaccreditation.com DNV Healthcare is the leading accreditor of US hospitals integrating ISO 9001 quality compliance with the Medicare Conditions of Participation. Our NIAHO® accreditation platform helps you achieve constant readiness. Dwelling at Ease Booth #1309 Located in the Wellness Pavilion New Exhibitor Dialog Medical Booth #706 30 Perimeter Park Drive Suite 200 Atlanta, GA 30341 800-482-7963 [email protected] www.dialogmedical.com Dialog Medical’s iMedConsent™ application produces easy-to-understand, procedure-specific consent forms, discharge instructions, and patient education materials. Trusted by over 200 hospitals, iMedConsent™ enhances safety, manages risk, ensures compliance, and lowers costs. Dimensional Insight Booth #801 60 Mall Road Burlington, MA 01803 781-229-9111 [email protected] www.dimins.com Hundreds of hospitals use The Diver Solution to tackle productivity, quality, revenue cycle, and clinical challenges. Clinical, financial, and operational data from multiple sources can be easily integrated with Diver. Booth #1007 1 Edwards Way Irvine, CA 92614 949-250-2500 [email protected] www.edwards.com Booth #612 101 North Acacia Avenue, Suite 101 Solana Beach CA 92075 858.473.2525 [email protected] www.creative-healthcare.com Edwards Lifesciences Jamestown, RI 02835 401-487-4434 [email protected] www.dwellingatease.com Dwelling at Ease® promotes fall prevention and home safety through real-time web-based systems that analyze and address hazards and obstacles to accessibility, reducing the risk of falls and accidental injuries. ECRI Institute Booth #308 5200 Butler Pike Plymouth Meeting, PA 19462 610-825-6000 [email protected] www.ecri.org ECRI Institute is an independent nonprofit that researches the best approaches to improving patient care. Our unbiased, evidence-based research, information, membership program, and educational services help you to lead your organization in assessing and addressing safety, quality, and risk management challenges. 25th Annual National Forum on Quality Improvement in Health Care Edwards Healthcare Provider Solutions is your expert advisor in clinical process improvement. Programs include the Sepsis Management Program and Post-Surgical Recovery Program focused on reducing critical complications in your hospital. Eloquest Healthcare, Inc. Booth #923 New Exhibitor 780 West Eight Mile Rd Ferndale, MI 48220 877-433-7626 [email protected] www.eloquesthealthcare.com We care about the care you deliver. At Eloquest Healthcare®, we focus on delivering easy-to-use product solutions that minimize infection risk, lower treatment costs, and increase patient and caregiver satisfaction. Elsevier Booth #313 245 Peachtree Center Ave NE Atlanta, GA 30303 866-430-7062 [email protected] www.clinicaldecisionsupport.com Elsevier is a global leader in providing health information and performance improvement solutions. Our worldclass information and point-of-care technologies optimize decisions and actions to improve the overall quality, safety, and cost-effectiveness of care. Endur ID Booth #215 8 Merrill Industrial Dr Hampton, NH, 03842 603-758-1488 [email protected] www.endurid.com Endur ID will be presenting our Patient Identification Solutions. Endur ID’s solution includes wristband media and software. Endur ID wristbands are in color, waterproof, easy to produce, and comfortable. Health Catalyst HealthStream, Inc. i2i Systems Booth #105 Booth #715 Booth #1006 Booth #1000 209 10th Avenue South, Suite 450 Nashville, TN 37203 615-301-3100 [email protected] www.healthstream.com 3663 N. Laughlin Road, Suite 200 Santa Rosa 707-575-7100 [email protected] www.i2isys.com Over half of US hospitals use HealthStream’s research, learning, simulation, and talent management solutions to improve outcomes. Learn how we support better healthcare quality and experiences on our website. A leading provider of population health and business intelligence solutions, i2i Systems helps health care organizations deliver better care more efficiently at a lower cost through software, services, and community. HealthTeamWorks Institute for Healthcare Improvement (IHI) New Exhibitor New Exhibitor 44 Montgomery St. Suite 3500 San Francisco, CA 94104 866-692-4271 [email protected] www.engineeredcare.com 3165 Millrock Drive, Suite 400 Salt Lake City, UT 84121 801-708-6800 [email protected] www.healthcatalyst.com From the hospital to the home, Engineered Care improves the patient experience with evidence-based, interactive solutions that manage the patient relationship. Health Catalyst provides a transformational approach to health care analytics and data warehousing. Learn more about our rapidly deployed data warehouse and quality improvement solutions by visiting our website. GE Healthcare Booth #223 N16W22419 Watertown Road Waukesha, WI 53186 877-438-4788 [email protected] www.gehealthcare.com/education GE Healthcare’s Fetal Heart Rate Monitoring Program and Nursing Library of Online Education with more than 50 courses helps clinicians stay current with best practices and optimize patient care. Georgia-Pacific Professional Booth #1205 New Exhibitor 133 Peachtree St. Atlanta, GA 30303 404-652-6132 [email protected] www.gp.com Georgia-Pacific Professional is a provider of hygienic dispensing systems, towels, tissues, soaps, cups and more including a full range of products to service the healthcare segment. It features well-known product brands enMotion® Compact® and Dixie®. Health Care DataWorks Booth #108 New Exhibitor 1801 Watermark Drive Columbus, OH 43215 614-255-5400 or 877-979-4239 [email protected] www.hcdataworks.com HCD empowers health care organizations to improve their quality of care and reduce costs. Our KnowledgeEdge™ solution delivers an Enterprise Data Warehouse that enables hospitals and health systems to gain operational visibility and insight. Health Dialog Booth #216 New Exhibitor Booth #1308 Located in the Wellness Pavilion 274 Union Blvd. Suite 310 Lakewood, CO 80228 303.446.7200 [email protected] www.healthteamworks.org New Exhibitor 60 State Street Suite 1000 Boston, MA 02109 617-406-5200 [email protected] www.healthdialog.com Health Dialog is a leading provider of health care analytics and decision support. Company offerings include health coaching for medical decisions, chronic conditions, and wellness; population analytic solutions; and consulting services. Health Information Alliance, Inc. (HIA) HealthTeamWorks is a nonprofit, multi-stakeholder collaborative working to redesign the healthcare delivery system and promote integrated communities of care using evidence-based medicine, practice transformation coaching, and innovative systems. Horizon Health Booth #214 New Exhibitor 2941 Lake Vista Drive, Ste 100 Lewisville, TX 75067 800-727-2407 [email protected] www.horizonhealth.com Booth #224 New Exhibitor Founded in 1981, Horizon Health Behavioral Health Services is the leading manager and provider of hospital-based behavioral health programs, working with hospitals of all types and sizes. 438 Marion Ave. Ambler, PA 19002 800-405-8800 [email protected] www.HIA-CORP.com HIA is focused on assisting its clients with the highest quality outcomes. HIA’s clients won the TJC’s Top Performers on Key Quality Measures this year as well as Thomson Reuters Top Hospitals. Healthier Hospitals Initiative Booth #912 12355 Sunrise Valley Drive Reston, VA 20191 703-405-8758 [email protected] www.healthierhospitals.org Healthier Hospitals Initiative (HHI) is a free, three-year initiative designed to accelerate the use of environmental interventions throughout the health care sector for improved health of patients, staff, and community. HQI Partners Booth #907 2966 South Church St Suite #247 Burlington, NC 27215 (336) 395-1420 [email protected] www.HQIpartners.com HQI Partners is a national provider of core measure abstraction and quality improvement consulting services. Our vision is to support our clients in the delivery of perfect care. EXHIBITORS Engineered Care, Inc. Booth #301 ISO Consultants for Healthcare Booth #1208 New Exhibitor PO Box 498 Greenville, Ohio, 45331 937-569-0173 [email protected] www.isoforhealthcare.com Nation’s leader in integrating health care and ISO 9001 quality management system. ICH provides system-oriented solutions through effective implementation, resulting in cost reduction and sustainable performance improvement-focused on patient outcomes. Gold Sponsor John Kim and Associates (JKA): Lean Healthcare Booth #417 3917 Kathleen Way Davenport, IA 52807 563-650-3822 [email protected] www.Johnkimconsulting.com An industry leading Lean health care consulting company specializing in the design, development, and implementation of Lean management systems customized to the specific needs of health systems, hospitals, physician practices and health plans. Which exhibit booths did you visit? Tweet it using #IHI25Forum 63 Exhibitors Joint Commission Resources Booth #1400 1515 W. 22nd St. Suite 1300W Oak Brook, IL 60523 630-268-7400 [email protected] www.jcrinc.com Joint Commission Resources (JCR) offers a full spectrum of resources to help health care professionals provide safe and efficient patient care through consulting services, education programs, publications and multimedia products. Platininum Sponsor Joint Commission Center for Transforming Health Booth #103 One Renaissance Blvd. Oakbrook Terrace, IL 60181 630-792-5630 [email protected] www.centerfortransforminghealthcare.org The Joint Commission Center for Transforming Healthcare offers the Targeted Solutions Tools, an innovative application that customizes solutions for your organization. Learn more about how it can help you reduce HAIs and more! Krames StayWell Booth #815 New Exhibitor 780 Township Line Road Yardley, PA 19067 267-685-2500 [email protected] www.kramesstaywell.com Krames StayWell is the nation’s largest provider of consumer health information, patient education, and population health management communications. Integrating print, digital, mobile, and social formats, Krames StayWell is proud to offer solutions, including a new health communication and patient engagement program exclusively for ACOs, to meet the needs of the changing health care environment. Lightshed Health Booth #914 New Exhibitor Lightshed gives you tools to manage your patients’ experience of waiting for care. They can skip the waiting room with UrgentQ. Booth #716 New Exhibitor Kaiser Permanente Booth #600 1 Kaiser Plaza Oakland, CA 94612 510-271-5953 Please use corporate hotline. www.kp.org Kaiser Permanente is committed to helping shape the future of health care and to providing high-quality, affordable health care services to our 9.1 million members and the communities we serve. 64 Medical Interactive Booth #1012 One Galleria Blvd., Suite 700 Metairie, LA 70001 855-464-7475 [email protected] www.medicalinteractive.com 901 Fifth Avenue, Suite 2000 Seattle, WA 98164 888-464-4746 [email protected] www.careguidelines.com MCG helps providers and payors drive effective care. We provide fast access to global, validated best practices so you can leverage your clinical expertise and make decisions with confidence. MCN Healthcare Booth #316 1777 S Harrison St Ste 405 Denver CO 80210 800-538-6264 pam.gustafson@mcnhealthcare. com www.mcnhealthcare.com MCN Healthcare is a leading provider of health care regulatory compliance solutions including Policy Manager, Policy Library, and StayAlert! – e-mail notification of regulatory changes and implementation tools. Visit our website to learn more. MedAssets Booth #1442 3423 Piedmont Rd. NE Atlanta, GA 30345 800-729-1363 [email protected] www.lightshedhealth.com Loyola University Chicago Niehoff School of Nursing Diamond Sponsor MCG — Formerly Milliman Care Guidelines 2160 S. First Avenue, Bldg. 125 Maywood, IL 60153 708-216-9101 [email protected] www.luc.edu/nursing Loyola University Chicago announces new Interprofessional Masters in Quality, Safety, and Information Technology (QSIT) for health care clinicians and leaders. This 36 credit program is online, with weekend immersion each semester. 100 North Point Center East Suite 200 Alpharetta, GA 30022 888-883-6332 [email protected] www.medassets.com MedAssets and Healthcare Performance Partners, a MedAssets Company, help health care organizations improve theiclinical, operational, and financial performance so they can sustainably serve the needs of their patients and communities. Medkinetics Booth #1001 124 First Avenue South, Suite 200 Franklin, TN 37064 888-880-OPPE [email protected] www.Medkinetics.com One system for event reporting, PSO, pee review, FPPE/OPPE, privilege’s with CPT/ICD-10 codes, credentialing, and payor enrollment. You don’t need another database, you need an interactive partner with proven results! 25th Annual National Forum on Quality Improvement in Health Care Booth #204 Medical Interactive offers resources designed to reduce RM expenses and increase productivity in med mal insurance companies and hospitals. Our comprehensive catalogue of products includes CME/CE and MiCapture™ RM software. Medical Simulation Corporation Booth #614 4643 S. Ulster St., #650 Denver, CO 80237 303-483-2800 [email protected] www.medsimulation.com Medical Simulation Corporation’s Advanced Quality Programs enable hospitals to measure, advance, and sustain health care provider knowledge of evidence-based guidelines for improved patient outcomes and reduced health care cost. Medworxx Booth #812 New Exhibitor 121 Richmond St W Suite 700 Toronto, ON, M8V 1T8 800-321-1591 [email protected] www.medworxx.com Medworxx provides health information technology solutions to over 350 hospitals internationally. Medworxx Patient Flow enables appropriate care transitions and fewer readmissions across the continuum of care. Midas+, a Xerox Company Booth #904 4801 East Broadway Blvd., Suite 335 Tucson, AZ 85711 520-296-7398 [email protected] www.midasplus.com With approximately 1,500 clients, Midas+ Solutions is the preferred health care quality outcomes improvement and strategic performance management partner. Minitab Booth #607 Monarch Medical Technologies (formerly EndoTool) Booth #1213 New Exhibitor 2815 Coliseum Ctr. Dr. Ste. 250 Charlotte, NC 28217 704-335-1300 [email protected] [email protected] www.monarchmedtech.com Monarch Medical Technologies is the leader in risk mitigation technologies for drugs and processes of concern. Its EndoTool Glucose Management System provides unsurpassed patient-specific control across a broad patient population. Morrisey Associates, Inc. Booth #1454 222 South Riverside Plaza, Suite 1850 Chicago, IL 60606 312-431-0123 [email protected] www.morriseyonline.com Established in 1987, Morrisey offers web-based care management (case, discharge networking, quality, risk and infection), credentialing and privileging applications, and comprehensive consulting services. Morrisey has over 900 health care customers. National Board of Surgical Technology & Surgical Assisting (NBSTSA) Booth #714 New Exhibitor 6 West Dry Creek Circle, Suite 100 Littleton, CO 80120 800-707-0057 [email protected] www.nbstsa.org The mission of the NBSTSA is to provide professional certification of surgical technologists (CST) and surgical first assistants (CSFA), thus promoting quality patient care in the surgical setting. NetHealth Booth #1422 #613 Gold Sponsor New Exhibitor 268 Summer Street, Sixth Floor Boston, Massachusetts 02210 617-391-9900 [email protected] www.npsf.org NPSF, an independent, not-for-profit 501(c)(3) organization, has been pursuing one mission since its founding in 1997 — to improve the safety of care provided to patients. National Research Corporation Booth #512 1245 Q Street Lincoln, NE 68508 800-388-4264 [email protected] www.nationalresearch.com 101 Lindenwood Drive, Suite 430 Malvern, PA 19355 610-590-2229 [email protected] www.nethealthinc.com Advanced technology and collaborative consulting with custom cloud-based PI-CME, SAM, LMS, PQRS, patient / peer surveys and outcomes evaluation; cutting-edge solutions that turn data into knowledge and knowledge into improvement. Gold Sponsor National Research Corporation empowers customer-centric health care across the continuum, transcending patient-centered care to incorporate families, communities, employees, and other stakeholders, and revealing performance improvement insights through quality measurement. NAVEX Global Booth #213 New Exhibitor 6000 Meadows Road, Suite 200 Lake Oswego, OR 97035 971-250-4100 [email protected] www.navexglobal.com NAVEX Global’s AHA endorsed policy & procedure management solution helps nearly 20 percent of the nation’s hospitals streamline the policy management lifecycle, eliminate paper binders, and meet audit standards. More than 8,000 clients trust our ethics and compliance expertise. Learn more on our website. NDNQI Booth #1002 8515 Georgia Avenue, Suite 400 Silver Spring, MD 20910 301-628-5042 [email protected] www.ndnqi.org NDNQI®, used by 2,000 hospitals nationwide, provides you with actionable data for quality improvement, via comparisons against nursing quality measurement norms of similar hospitals down to the unit level. North Shore-LIJ Health System Booth #507 145 Community Drive Great Neck, NY 11021 516-465-8000 [email protected] www.northshorelij.com EXHIBITORS 1829 Pine Hall Road State College, PA 16801 814-238-3280 [email protected] www.minitab.com Minitab is the leading provider of powerful and easy-to-use quality improvement software worldwide. Companies rely on Minitab software, training, and services to help them achieve world-class quality. National Patient Safety Foundation North Shore-LIJ is the nation’s 14th largest health care system, serving more than seven million people throughout the NYC metro area. We partner with IHI and others on patient safety, performance improvement, research and education. Nuance Communications Inc. NEXT LEVEL Partners, LLC Booth #902 2338 Immokalee Road, Suite 415 Naples, FL 34110 216-632-0070 [email protected] www.nl-p.com NEXT LEVEL Partners, LLC is the partner of choice if true transformation into a culture of continuous performance improvement is desired. Differentiators in our partnership include competency development structure, no minimum timeframe of partnering work and, most importantly, a results guarantee. Booth #805 1 Wayside Road Burlington, MA 01803 800-447-7749 [email protected] www.nuance.com/for-healthcare/ index.htm Nuance provides intelligent solutions and services, improve the entire clinical documentation process—from capture of the complete patient record to clinical documentation improvement, coding, compliance, quality and appropriate reimbursement. Outcome, a Quintiles Company Booth #1003 Nihon Kohden America, Inc. Booth #107 90 Icon Street Foothill Ranch, CA 92610 949-580-1555 [email protected] nk.usa.com Nihon Kohden will display a complete line of enterprise monitoring solutions, including a robust transport system and external device interfaces. We will highlight clinical benefits of implementing a Defensive Monitoring strategy with our Prefense™ Early Detection and Notification System™. 201 Broadway Cambridge, MA 02139 617-621-1600 [email protected] www.outcome.com Outcome is a leading provider of web-based quality measurement systems for quality-improvement (QI), pay-for performance, reimbursement, accreditation, and certification programs, providing hospitals and physician practices with solutions and resources to ensure quality improvement in patient care. Which exhibit booths did you visit? Tweet it using #IHI25Forum 65 Exhibitors PeraHealth PowerDMS Booth #200 Booth #900 New Product Release 1520 South Blvd. Charlotte, NC 28203 866-362-0001 [email protected] www.perahealth.com PeraHealth offers real time, clinical decision support tools that provide a visual representation of patient condition. Rooted in the peer reviewed Rothman Index™, our tools serve the continuum of care. Performance Logic Booth #913 901 SE Oak St., Suite 205 Portland, OR 97214 888-407-1705 [email protected] www.performancelogic.com Performance Logic provides compre hensive, web-based project portfolio management solutions designed to help healthcare organizations manage projects in IT, clinical, and operational areas while aligning resources and goals enterprise-wide. Physician Wellness Services Booth #809 5000 W 36th St #230 Minneapolis, MN 55426 800-383-1908 [email protected] www.physicianwellnessservices.com Physician Wellness Services provides a coordinated, comprehensive, and confidential suite of services designed specifically for physicians and organizations. We are national, and have expertise in every aspect of behavioral health. Phytel Booth #312 11511 Luna Road, Suite 600 Dallas, TX 75234 800-559-3057 [email protected] www.phytel.com Empowering physician-led population health improvement, Phytel provides proven technology to deliver coordinated patient care. Encompassing 30 million+ patients, Phytel’s registry uses evidence-based protocols to identify and notify patients due for service. 66 Media Sponsor PO Box 2468 Orlando, FL 32802 407-992-6066 [email protected] www.powerdms.com PowerDMS™ provides a compliance and document management solution that helps reduce risk and liability with practical tools to organize and manage crucial documents and standards, train employees, and prove compliance. PQ Systems Booth #606 210B E Spring Valley Rd Dayton, OH 45458 800-777-3020 [email protected] www.pqsystems.com PQ Systems is dedicated to helping health care professionals provide proof of quality. Our highly regarded CHARTrunner Lean software is the easiest solution for improving health care quality. Premier Healthcare Alliance Booth #401 13034 Ballantyne Corporate Place Charlotte, NC 28277 877-777-1552 [email protected] www.premierinc.com Premier is one of the nation’s largest performance improvement alliances of approximately 2,800 U.S. community hospitals and 98,000 alternate sites using the power of collaboration and technology to lead the transformation to coordinated, high-quality, costeffective care. Press Ganey Booth #307 401 Edgewater Drive Wakefield, MA, 01880 978-985-7726 [email protected] www.pressganey.com Recognized as a leader in performance improvement for nearly 30 years, Press Ganey partners with more than 10,000 healthcare organizations globally to create and sustain high performance and improve the overall patient experience. Patient Safety and Quality Healthcare www.psqh.com QI Macros Lean Six Sigma Software for Excel Booth #101 2696 S Colorado Blvd, Suite 555 Denver, CO 80222 888-468-1537 [email protected] www.qimacros.com QI Macros Software for Excel simplifies process improvement for pareto charts and control charts. Contains 90+ templates including fishbones and flowcharts. Used by 3,000+ hospitals. $229/copy. Free 30-day trial. Quantros, Inc. Booth #903 475 Sycamore Drive Milpitas, CA 95035 877-QUANTROS [email protected] www.quantros.com Quantros empowers health care providers with actionable intelligence necessary to improve outcomes. Our SaaS-based solutions offer safety and risk management, quality and performance improvement, accreditation and compliance, and centralized decision support. Rapid Modeling Corporation Booth #622 8044 Kimbee Drive Cincinnati, OH 45244 513-624-6629 [email protected] www.rapidmodeling.com RMC developed Time Study RN/MD for TCAB and manages the Time Study RN National Benchmarking Database. RMC is the supplier for Lean solutions for hospitals and health care organizations throughout North America. 25th Annual National Forum on Quality Improvement in Health Care ReadyPoint Systems Booth #1113 40 Burton Hills Blvd., Ste 150 Nashville, TN 37215 866-506-1930 [email protected] www.readypointsystems.com ReadyPoint’s EyeOn tool automates rounding and survey processes. Using a mobile device, users complete customized surveys and alert staff for corrective actions. Management receives notification of missed target dates then reminds users to take action. RF Surgical Systems, Inc. Booth #517 5927 Landau Ct. Carslsbad, CA 92008 760-827-1500 [email protected] www.rfsurg.com The RF Assure Detection System® brings innovation, simplicity, confidence, and compliance to hospitals by providing an easy to use, accurate system for detecting and preventing retained surgical sponges. RGP Healthcare Booth # 523 New Exhibitor 90 New Montgomery Street Suite 1301 San Francisco, CA 94105 415-369-8441 [email protected] www.resourcesglobal.com RGP Global formalized its offerings into RGP Healthcare, leveraging core competencies—project and change management, and functional and healthcare industry expertise—to ensure client success on mission-critical initiatives. Right Brain Left Brain, LLC Booth #222 New Exhibitor 2220 CR 210 West, Suite 108-211 Jacksonville, FL 32259 904-302-2939 [email protected] www.rightbrain-leftbrain.net Right Brain Left Brain is a hospital and physician clinic services company focused on patient centric transformation improving quality, service, and value. We enable Joint Commission certifications and Medicare alignment. RightCare Solutions Booth #1209 Skylight Healthcare Systems Gold Sponsor IHI Supporter Booth #813 New Exhibitor RightCare Solutions provides evidence-based software technology that empowers nurses, discharge planners, and case managers to optimize care transitions and improve patient outcomes. Our proprietary D2S2 software, helps hospitals, insurers and homecare agencies improve the quality of care for patients while reducing 30-day readmissions. RL Solutions Booth #701 New Exhibitor One Broadway, 14th Floor Cambridge, MA 02142 888-737-7444 [email protected] www.rlsolutions.com RL Solutions designs innovative health care software for patient feedback, risk management, infection surveillance, root cause analysis and claims management. We have over 1300 clients, including health care networks, hospitals, long-term care facilities, and more. Safer Healthcare Booth #1456 PO Box 1010 Littleton, CO 80160-1010 866-398-8083 [email protected] www.saferhealthcare.com Improve and automate rounding with MyRounding™. Take quality improvement to the next level with our Lean workshops. Become a High-Reliability Organization with our CRM solutions. Sandlot Solutions 10935 Vista Sorrento Parkway, Suite 350 San Diego, CA 92130 858-523-3700 [email protected] www.skylight.com Booth #1013 New Exhibitor 1701 River Run, Suite 902 Fort Worth, TX 76107 817-810-5210 [email protected] www.sandlotsolutions.com Skylight Healthcare Systems is the industry leader in interactive patient systems supporting the continuum of a patient’s “journey of care” before, during, and after the hospital stay. Sandlot builds connections for providers that enable the exchange of relevant clinical content at the point of care through “cloud” technology. Our five-year track record of success has facilitated reduced cost, coordinated utilization, improved quality, and elevated patient satisfaction. Sandlot’s capabilities provide the bridge to gaps in care without exorbitant re-engineering of current systems and the associated expense. SprectraMEDIX Booth #917 New Exhibitor 66 Witherspoon Street, Suite 104 Princeton, NJ 08077 609-336-7733 [email protected] www.SpectraMEDIX.com SpectraMEDIX empowers hospitals and ambulatory care providers to improve care and maximize revenues. Our solutions transform real-time clinical data into actionable information that facilitates improved, measurable clinical and financial results. Gold Sponsor Simpler Healthcare SurgiCount Medical Booth #306 401 Liberty Avenue Pittsburgh, PA 15222 336-283-4060 [email protected] www.simpler.com Booth #1143 New Exhibitor Using the Simpler Business System®, Simpler sensei have delivered the fastest and most enduring Lean transformations at more than 85 health care networks around the world. 15440 Laguna Canyon Road Suite 150 Irvine, California 92618 877-520-2300 [email protected] www.scmd.com The Safety-Sponge® System utilizes uniquely identified sponges, lap, and towel products, providing more accurate, real-time counts in the operating room as well as a complete post-operative documentation and compliance tool. SIMUL8 Corporation Booth #104 225 Franklin Street Boston, MA, 02110 800-547-6024 [email protected] www.SIMUL8healthcare.com The Beryl Institute 3600 Harwood Rd. Bedford, Texas 76021 866-465-5824 [email protected] www.theberylinstitute.org The Beryl Institute is the global community of practice and premier thought leader on improving the patient experience in health care. EXHIBITORS 110 Gibraltar Rd Horsham, PA 19044 215-660-3436 [email protected] www.rightcaresolutions.com New Exhibitor The Chartis Group Booth #909 220 West Kinzie Street, 5th Floor Chicago, Illinois 60654 877-667-4700 [email protected] www.chartisgroup.com The Chartis Group is an advisory services firm that provides management consulting and applied research to leading health care organizations. We specialize in helping health systems with clinical quality improvement. The Compliance Team, Inc. Booth #205 PO Box 160 Spring House, PA 19477 215-654-9110 [email protected] www.thecomplianceteam.org The Compliance Team’s operationsdriven Exemplary Provider™ accreditation for critical access hospitals eliminates unnecessary distractions and non-essential expenses while taking a common sense, low-cost, Gemba Kaizeninspired approach to achieving health care delivery excellence. For over 20 years, SIMUL8 has been dedicated to improving health care with simulation software. Our customers include Geisinger, Johns Hopkins, FUNSALUD, and the UK National Health Service. Which exhibit booths did you visit? Tweet it using #IHI25Forum 67 Exhibitors Diamond Sponsor The Joint Commission Booth #1404 One Renaissance Boulevard Oakbrook Terrace, IL 60181 630-792-5689 [email protected] www.jointcommission.org The Joint Commission accredits and certifies more than 20,000 organizations. We provide an educative experience that helps organizations provide safe, high quality care and resources to help sustain that care. The Quality Group, Inc Booth #615 New Exhibitor 5825 Glenridge Dr, Suite 3-101 Atlanta, GA 30328 404-843-9525 [email protected] www.thequalitygroup.net The Quality Group (TQG) helps dive Lean with health care-only e-learning modules. Engage all in process improvement (Lean, six sigma, project management) via a customized, blended learning e-portal; deliver ROI through better processes and better patient care. The STEEEP® Global Institute Booth #816 New Exhibitor 8080 N. Central Expressway Suite 900, LB 77 Dallas, TX 75206 214-265-3614 [email protected] www.baylorhealth.edu/ steeepglobalinstitute/ Pages/default.aspx Baylor Health Care System’s STEEEP Global Institute offers training and consulting services to help external organizations improve health care quality in the areas of safety, timeliness, effectiveness, efficiency, equity, and patient-centeredness. 68 Diamond Sponsor University of Michigan Healthcare Programs Booth #901 The University of Tennessee Booth #617 Truven Health Analytics 603 Haslam Business Building 1000 Volunteer Blvd Knoxvile, TN 37996-4160 865-974-5001 [email protected] www.execed.utk.edu Booth #201 UT offers CME-certified programs and the nation’s #1 Physician Executive MBA; delivers custom Lean health care, Lean ED, Lean OR and Lean for Outpatient Settings courses; and orchestrates on-site PI /QI events. Truven Health Analytics delivers leading solutions for confident health care management. From population health and quality performance improvement analytic platforms to operational performance solutions, we help hospitals, providers, and payers improve quality, safety, efficiency, and patient outcomes. The Wellness Network 6200 S. Syracuse Way, Suite 300 Greenwood Village, CO 80111 303-486-6540 [email protected] www.truvenhealth.com Booth #916 N27 W 23539 Paul Road, Suite 100 Pewaukee, WI 53072 888-219-4678 [email protected] www.thewellnessnetwork.tv The Wellness Network owns and operates the Patient Channel and the Newborn Channel; together the largest and most comprehensive in-hospital health television network in the U.S. The Wellness Network is also a long-time partner with the Joint Commission Quality & Safety Network. Thermo Scientific Booth #1100 8365 Valley Pike Middletown, VA 22645 800-232-3342 customerservice.diagnostics.mtn@ thermofisher.com www.thermoscientific.com\ aboutsepsis The Thermo Scientific’s B•R•A•H•M•S line of immunoassays facilitate earlier diagnosis of diseases and better control of therapy, thus enabling doctors to improve patient outcomes. UL, LLC (Underwriters Laboratories) Booth #1440 8131 Baymeadows Circle West Suite 208 Jacksonville, FL 32256 904-318-7086 [email protected] www.ul.com/lean UL has brought together its own Lean and six sigma transformation and world-class leadership to accomplish one mission: improve value to the customer by providing higher quality and safety with less waste. UL trains, certifies, assesses and advises individuals and organizations in principles of continuous improvement. University of Illinois at Chicago, College of Medicine, Department of Medical Education Booth #1420 808 South Wood Street (MC 591) Chicago, Illinois 60612-7309 866-722-2268, Option 1 [email protected] go.uic.edu/mpslihi UIC’s Department of Medical Education offers an online masters and graduate certificate in patient safety. These programs develop leaders in quality patient care practices, able to advance an organizational culture of patient safety. 2401 Plymouth Road Ann Arbor, Michigan 48105-2193 734-647-7200 [email protected] isd.engin.umich.edu University of Michigan health care, management, and engineering experts offer world-class Lean health care training with interactive hands-on experience. Programs can be customized for your health care system. University of St. Thomas Health Care MBA Booth #823 1000 LaSalle Ave. TMH455 Minneapolis, MN 55403 651-962-4135 [email protected] www.StThomas.edu/HealthCareMBA Representing the entire health care sector, our students are experienced industry professionals. They build a foundation in business, critical thinking and leadership while developing a deep understanding of the health care industry. Verge Solutions Booth #314 P.O. Box 394 Mt. Pleasant, SC 29465 843-628-4168 [email protected] www.verge-solutions.com Verge Solutions offers SaaS solutions to automate administrative processes. Combining the collective wisdom of our customers with software expertise, we understand technology is key for better outcomes and lower costs. Platinum Sponsor VHA Booth #707 290 East John Carpenter Freeway Irving, Texas 75062 972-830-0000 [email protected] www.vha.com VHA is a national network of not-forprofit health care organizations that work together to set new levels of clinical performance, establish best practices to improve operational efficiency, and gain maximum savings in the supply chain arena. 25th Annual National Forum on Quality Improvement in Health Care VigiLanz Corporation Vocera Booth #1206 Booth #712 VigiLanz real-time software-as-aservice surveillance solutions for infection control, pharmacy, and quality programs enable expedited NHSN submission, HAI tracking, robust analysis, reports, and antimicrobial stewardship, optimizing clinical outcomes and efficiencies. Virginia Mason Institute Booth #1436 1100 Olive Way Suite 501 Seattle, WA 98101 206-341-1600 [email protected] www.virginiaMasonInstitute.org Experience-based learning in the Virginia Mason Production System (VMPS). Meet our faculty to learn how your organization can: Improve quality and safety for patients, eliminate waste, and improve staff satisfaction. Vocera provides innovative care experience solutions that restore the human connection in care, resulting in better care team communication, improved patient satisfaction and safety, reduced readmission rates, and market differentiation. Booth #501 10880 Wilshire Blvd. Suite 300 Los Angeles, CA 90024 310-954-1950 [email protected] www.zynxhealth.com New Exhibitor 525 Race Street San Jose, CA 95126 800-331-6356 [email protected] www.vocera.com Zynx Health Vree Health Booth #1214 351 N Sumneytown Pike North Wales, PA 19454 267-305-2507 [email protected] www.vreehealth.com Zynx Health, subsidiary of Hearst Corporation, is the market leader in providing evidence-based clinical decision support solutions that help health care organizations measurably improve patient outcomes, enhance safety, and lower costs. EXHIBITORS 5775 Wayzata Boulevard, Suite 970 Minneapolis, MN 55416 855-525-9078 [email protected] www.vigilanzcorp.com Platinum Sponsor Vree Health is a wholly-owned subsidiary of Merck.arge service, TransitionAdvantage™, combines innovative technology and personal patito help coordinate care and reduce readmissions. International Forum on Quality and Safety in Healthcare 8 - 11 April 2014, Paris Improve quality. Reduce costs. Save lives. Book now and save up to £247 Early Bird ends 31 January 2014 Attend the 19th Annual International Forum: • Be inspired by the international improvement community with representatives from over 80 countries. • Expand your network, learn and gather new practical ideas for your quality improvement and patient safety initiatives. The 2013 Forum sold out early. Reserve your place now at: internationalforum.bmj.com North Shore-LIJ Health System is Committed to Providing the Safest, Highest Quality Care to the Communities We Serve Building on our partnerships with IHI and other leading organizations to innovate and transform healthcare for the future, North Shore-LIJ continues to focus on: • Ensuring value by delivering high quality, reliable and efficient care • Eliminating the incidence of healthcare-acquired conditions • Early sepsis diagnosis and treatment resulting in reduced mortality • Improving care for patients with advanced illness • Educating the next generation of physicians and healthcare professionals To learn more, visit us at Booth #507 in the Exhibit Hall or online at northshorelij.com. 70 Thank You TO OUR CHAIRS acknowledgements Acknowledgements IHI would like to thank the National Forum co-chairs for their extraordinary effort and commitment in developing the program for the 2013 National Forum: Mark Smith, MD, MBA, President and CEO, California Healthcare Foundation Michael Dowling, President and CEO, North Shore-LIJ Christian Farman, Registered Nurse, Ryhov County Hospital Molly Joel Coye, MD, MPH, Chief Innovation Officer, UCLA Health System, Institute for Innovation in Health All planning committee members and persons influencing the content of the National Forum program have disclosed all relevant financial relationships with any commercial interest to the Institute for Healthcare Improvement. IHI would like to thank our board of directors For their ongoing support and guidance James M. Anderson, Advisor to the President Cincinnati Children’s Hospital Medical Center Cincinnati, OH A. Blanton Godfrey, PhD Dean and Professor College of Textiles North Carolina State University Raleigh, NC Arnold Milstein, MD, MPH Medical Director Pacific Business Group on Health San Francisco, CA Maureen Bisognano President and CEO Institute for Healthcare Improvement Cambridge, MA Jennie Chin Hansen CEO American Geriatrics Society New York, NY Dennis S. O’Leary, MD President Emeritus The Joint Commission Oakbrook Terrace, IL Helen Haskell Founder and President Mothers Against Medical Error (MAME) Columbia, SC Rudolph F. Pierce, Esq. Attorney (Of Counsel) Goulston & Storrs, PC Washington, DC Michael Dowling President and CEO North Shore – LIJ Great Neck, NY Elliott S. Fisher, MD, MPH Director for Population Health and Policy The Dartmouth Institute for Health Policy and Clinical Practice Lebanon, NH Terry Fulmer, PhD, RN, FAAN Dean, Bouvé College of Health Sciences Northeastern University Boston, MA Brent C. James, MD, MStat Chief Quality Officer Executive Director, Institute for Healthcare Delivery Research Intermountain Healthcare Salt Lake City, UT Gary S. Kaplan, MD Chairman & CEO Virginia Mason Medical Center Seattle, WA 25th Annual National Forum on Quality Improvement in Health Care Nancy L. Snyderman, MD, FACS Chief Medical Editor, NBC News Associate Professor of Otolaryngology, University of Pennsylvania New York, NY Diana Chapman Walsh, MS, PhD President Emerita Wellesley College Wellesley, MA 71 This is what can happen if your incident tracking is incomplete. Isn’t a“solution” supposed to solve problems? There are more than 200,000 preventable patient deaths each year. 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The exclusive benefits of a yearlong membership for $5,000 include: • Unlimited participation in Expeditions—two-to-four month, web-based programs led by expert faculty and designed to address your organization’s highest improvement priorities • Registration for Leading Quality Improvement: Essentials for Managers—a three-month virtual program designed to teach your middle managers the skills they need to lead improvement at your organization • A 25% IHI Open School online course subscription discount • Other tools, including on-demand podcasts, videos, and presentation materials Join the hundreds of other Passport members—become a member today! Learn more, and network with existing members, at the Special Interest Breakfast: Wednesday, December 11th 7:00 AM – 7:45 AM Anaheim 73 Mark your calendar for next year’s 26th Annual National Forum on Quality Improvement in Health Care: December 7–10, 2014 ORLANDO, FL Stay connected with IHI and your fellow National Forum attendees until next December! Follow us on Twitter, Facebook, and LinkedIn to stay updated on all the National Forum news. FACEBOOK LINKEDIN TWITTER Statistical Software It’s easy to achieve all your quality improvement goals when you analyze your data with Minitab 16. Thousands of world-class companies choose Minitab because it has the tools they need and is easy to use, thanks to features like an interactive Assistant that guides you through your analysis. Don’t just improve your business – transform it. www.minitab.com Minitab Inc. provides exceptional sales, technical support and training for Minitab 16. For more information, visit www.minitab.com 75 N O R T H W E S T E R N U N I V E R S I T Y The Time is Now. Take the Lead. PROGRAM DIRECTORS: Kevin Weiss, MD, MPH Professor of Clinical Medicine Feinberg School of Medicine Northwestern University Donna Woods, EdM, PhD Associate Professor Feinberg School of Medicine Northwestern University Graduate Programs in Healthcare Quality and Patient Safety •MasterofSciencedegreeinHealthcareQualityandPatientSafety A two-year, part-time degree program which focuses on the knowledge, skills, and methods necesary for improving healthcare delivery systems. It is designed for both clinical and non-clinical professionals currently working in the healthcare setting who want to focus their career development on these important areas GUEST FACULTY INCLUDE: James Bagian, MD, PE in healthcare. Engineer and former NASA Astronaut •FacultyDevelopmentPrograminHealthcareQualityandPatientSafety James Battles, PhD tools, methods, and curricular approaches for integrating healthcare quality Agency for Healthcare Research & Quality (AHRQ) Carmella Bocchino, RN, MBA America’s Health Insurance Plans Helen Burstin, MD, MPH National Quality Forum A one-year program designed for faculty who wish to develop the educational and patient safety into the medical education curriculum. •CertificatePrograminHealthcareQualityandPatientSafety A one-year program designed for the learner who wants to acquire a comprehensive overview of these fields. John Gosbee, MD, MS Human Factors Engineering & Healthcare Specialist Martin Hatlie, JD Partnership for Patient Safety The above programs are all part-time and do not require Chicago residence. Students are required to travel to our Chicago campus for a series of classroom-based intensive sessions. Accommodation is available at select local area hotels at a reduced rate. Karen Kmetik, PhD American Medical Association Julie Johnson, MSPH, PhD For more information, please contact University of New South Wales Meetal Acharya at [email protected] L. Gregory Pawlson, MD, MPH or by phone at 312-503-5533. Derek Robinson, MD, MBA Please visit our website at: American Hospital Association www.northwestern.edu/quality-safety Kathleen Sutcliffe, PhD, MSN University of Michigan Ross School of Business Robert Wears, MD, MS, PhD University of Florida and Imperial College London United Airlines Corporate Safety Team 76 “The need for leadership in health care has never been greater…” 25th Annual National Forum Improvement intheHealth Care — fromon The Quality Institute of Medicine report, Crossing Quality Chasm 77 25th Annual National Forum on Quality Improvement in Health Care AND CONGRATULATIONS THANK YOU Institute for Healthcare Improvement for your 25 years of improving health care; and for your continued commitment to support health care professionals. Visit Edwards Lifesciences, booth #1007, to learn how you can standardize care to reduce post-surgical complications. Edwards, Edwards Lifesciences, and the stylized E logo are trademarks of Edwards Lifesciences Corporation. © 2013 Edwards Lifesciences Corporation. All rights reserved. 0005-CC-11.12 Edwards Lifesciences | edwards.com Irvine, California 92614 USA Congratulations to the Institute for Healthcare Improvement on the 25th Anniversary of the IHI National Forum The more than 46,000 team members of North Shore-LIJ Health System are proud of our collaboration with IHI on initiatives to improve healthcare quality and patient safety. We look forward to working together for many more years to improve the health of people around the globe. Michael J. Dowling President and CEO North Shore-LIJ Health System Great Neck, New York Chair, IHI Forum 2013 Secretary-Treasurer, IHI Board 17425 IHI Forum 25th Anniversary Guide 13 Ad: 8x5 79 Join IHI and over 1,000 engaged improvers as we harness the power of collaboration and set bold ideas in motion. Reserve your spot at the 15th Annual Summit on Improving Patient Care in the Office Practice and the Community, and be part of a dynamic gathering of your colleagues and thought-leaders from around the globe. Over the course of three days and more than 60 sessions, we’ll explore cutting-edge improvements for office practices, outpatient settings, and communities. As the tides change once again in health care, we’ll seek out new ways to create a culture of continuous improvement, engage patients and communities in redesigning care, and chart a bold new course for the future. This year’s keynote speakers are not to be missed: • Laura Adams, President and CEO, Rhode Island Quality Institute • Derek Feeley, Executive Vice President, IHI • Ed Wagner, MD, MPH, Director, Group Health Cooperative Enroll today! ihi.org/ihisummit ➜ as a HealtHcare leader, wHat issues in your organization keeP you uP at nigHt? ➜ ➜ do you know How to address tHeM? stakes are HigH, so can you afford just anotHer ‘good try’ tHis tiMe? When your organization needs more than just a good effort. When you need guaranteed, reliable and sustainable results, quickly… you need to take it to the NEXT LEVEL. Partnering improvement examples: in aVerage or turn-oVer time • ➜ C-seCtion infeCtion rate from 17% to 0 • ➜ ➜ ➜ • 40 min reVenue CyCLe CHarge CaPture by $1.8m ➜ ➜ ➜ bed PLaCement time by 23% • • • • sCiP-7 ComPLianCe rate from 20% to 100% CentraL steriLe ProCess time by 50% Mike Holland Vice President – Lean Healthcare NEXT LEVEL Partners®, LLC mholland@nl-p (212) 632-0070 www.nl-p.com key differentiators: • N ominimumtimefor engagement • Resultsguarantee • S tructuredclient development process to ensureknowledgetransfer instrument set inVentory by $146K Please come see us in BootH #902 at the iHi forum • december, 8-11, 2013 • orlando, fl 81