|
About 350 health-care professionals and patient advocates attended the 2008 Minnesota Alliance for Patient Safety (MAPS) conference held in the Twin Cities Nov. 13-14, 2008.
The conference, "Road Maps to Patient Safety: Accelerating for Change," highlighted successful efforts by providers in Minnesota and from other parts of the country to improve the safety and quality of care provided to patients. Attendees heard nationally prominent experts in quality improvement and attended more than a dozen breakout sessions and seminars.
National experts included Lucian Leape, M.D., of the Harvard School of Public Health, James Conway, executive vice president/COO, Dana-Farber Cancer Institute, Boston, Eric Coleman, M.D., University of Colorado Health Science Center, and others.
Conway spoke at the conference and at a special dinner event for MMA members. At the conference, Conway said that health care leaders have suffered from a failure of will and execution in the arena of patient safety and quality.
To change this, health care leaders need to ground themselves and their organization in the suffering that errors and poor care can cause patients.
"There is nothing that is going to build will more than a focus on the patients who suffer," he said.
Leaders should turn to patients for help and consult with them in order to use their insights to improve their organizations, he said.
Conway also suggested getting chief financial officers involved in an organization's quality improvement efforts, because CFOs will see that improving quality and reducing errors will result in bottom line savings.
To get physicians involved, leaders need to use data that shows that the proposed changes will result in improved outcomes, he said. "If we are in the clinical space, we will not achieve our aims without engaging physicians."
MAPS also gave out its annual awards to:
Steven Kleinglass, medical center director, Veterans Affairs Medical Center, Minneapolis: Individual Leadership in Patient Safety Award
Kleinglass was recognized for his years of outstanding work to advance the culture of safety at the VA Medical Center, Minneapolis. Kleinglass is committed to teamwork, and his personal dedication to patient safety has evolved to change a hospital culture. He is a well respected and effective leader for patient safety throughout the state as evidenced by his past leadership role as chair of the MHA Patient Safety Committee.
North Memorial Medical Center, Robbinsdale: Process/System Innovation Award
North Memorial was recognized for improving organization-wide hygiene compliance from 38 percent to 90 percent. After an initial pilot identified a major patient safety risk for hospital-acquired infections because of hand hygiene non-compliance, North Memorial quickly moved to implement phase two of the pilot where the hospital’s senior leadership designated hand hygiene as one of its top priorities in 2007. The second phase resulted in further development of a rigorous hand hygiene accountability system and the project was translated throughout the hospital. Performance measures are now in place to maintain high levels of compliance.
Lake Region Healthcare Corporation, Fergus Falls: Dissemination/Spread Innovation Award
In May 2007, Lake Region joined the MHA’s SAFE from FALLS Call-to-Action program. They used the opportunity to enhance their current falls prevention program to improve patient safety, decrease length of stays, and improve patient satisfaction. Through interdisciplinary process improvements, Lake Region’s falls prevention program currently goes beyond the inpatient and outpatient setting to incorporate the community setting.
University of Minnesota Medical Center, Fairview and University of Minnesota Children’s Hospital, Fairview, Minneapolis: Patient/Family Engagement Award
The University of Minnesota Medical Center, Fairview and University of Minnesota Children’s Hospital, Fairview, reduced infections in the neonatal intensive care unit. Parents were engaged to assist in the unit-wide initiatives, and the combination of prevention efforts resulted in a 30 percent reduction in late onset infections in infants with very low birth weights over the past two years. The multi-faceted approach included implementation of clinical best practices, improved hand washing among staff and parents, and the creation of a “sacred space” — a clean, clutter-free area — around the infants. Parents of former infant patients were engaged to create compelling parent education materials.
Here is a list of the presentations at the conference by topic.
Accelerating improvement
Susan Nelson, R.N., director, project consulting group, and Craig Svensen, M.D., chief medical quality officer, HealthEast Care System, St. Paul, MN, described how HealthEast applied the accelerated improvement model to prevent venous thromboembolism.
Adverse health events
Julie Apold, director, patient safety, Minnesota Hospital Association, St. Paul, MN and Diane Rydrych, assistant director, division of Health Policy, Minnesota Department of Health, St. Paul, MN, discussed Minnesota’s adverse events reporting law, which was approaching its five-year anniversary. They shared key findings and strategies for reducing adverse events.
Clinic safety
Patrick Courneya, M.D., associate medical director, HealthPartners, Inc., Minneapolis, MN, spoke about HealthPartners efforts to develop methods to reduce adverse events and near misses in ambulatory care setting. Courneya discussed the "Ambulatory Patient Safety Toolkit" that HealthPartners developed in 2007 and updated in October. The toolkit includes safety protocols, guidelines, forms, and topic areas that clinics should focus on. The kit is available at http://www.healthpartners.com/files/34649.pdf .
Complexity compression
Patty Koenig, R.N., B.S.N., staff nurse and Kathie Krichbaum, Ph.D., R.N., associate professor, University of Minnesota School of Nursing, Minneapolis, MN, focused on the phenomenon of "complexity compression" that has been described and validated by groups of nurses at the point of care.
Communicating lab results
Tery Murray, quality coordinator, Quello Clinic, Bloomington, MN and Becky Rose, laboratory director, Quello Clinic, Minneapolis, MN, were part of a primary care team that took steps to improve the reliability and timeliness of laboratory results to patients.
Disclosing errors
Phillip M. Kibort, M.D., M.B.A, vice president, medical affairs, chief medical officer, Children’s Hospitals and Clinics of Minnesota, discussed Children’s policy to fully disclose adverse events to families including the barriers to disclosing such information and how Children’s overcame those barriers.
Electronic health records and care transitions
Jerome Siy, M.D., hospitalist and chief of professional services, and Julie Weegman, nurse manager, Oncology, Regions Hospital, St. Paul, MN, addressed how to keep the use of electronic medical records from resulting in communication breakdowns among providers.
Family advisory councils
Jim Conway, executive vice president/COO, Dana-Farber Cancer Institute, Boston, MA, discussed ideas for successful engagement of patients and their families and provided a forum to discuss barriers, success factors and strategies that might be helpful.
Health literacy
Bette-Jo Johnson, associate nurse manager, Park Nicollet Methodist Hospital, St. Louis Park, MN, discussed the relevance of health literacy to patient care, provided clinical tips for communicating effectively with patients, and discussed the relationship between health literacy and informed consent.
High reliability model
Karen Tucker, nurse manager, Cincinnati Childrens, Cincinnati, OH, discussed how one 24-bed general medical unit used high reliability concepts to sustain several outcomes, such as reducing codes, incorporating evidence-based care guidelines into practice, and reducing central venous catheter infections.
Human factors and safety
Thoralf M. Sundt III, M.D., Division of Cardiovascular Surgery, Mayo Clinic, Rochester, MN, discussed how human factors science -- how humans interact with products, procedures, processes and tools -– can help improve health care.
Sundt spoke about his own experiences as a surgeon and how the loss of a patient because of an air-bubble that was pumped into the patient’s brain during a heart transplant surgery profoundly affected him and led him to study error prevention and the field of human factors science.
Measuring safety
Barbara Balik, R.N., Ed.D., principal, Common Fire Healthcare Consulting, Albuquerque, NM and Trista Johnson, Ph.D., director of quality and outcomes, physician division, Providence Health and Services, Beaverton, OR, discussed the difficulties of developing useful, accurate and efficient safety measures.
MRSA infections
Noe Mateo, M.D., infection control medical director, and Stephanie Tismer, infection control practitioner, Regions Hospital, St. Paul, and Tom Michels, infection control practitioner, HealthPartners Inver Grove Heights Clinic, Inver Grove Heights, MN, discussed the challenges of preventing, detecting, and managing MRSA-colonized and infected patients in clinics, hospitals and nursing homes.
National overview
Lucian Leape, M.D., Harvard School of Public Health, in his presentation "The Patient Safety Journey" reviewed the state of patient safety in the United States since the release of the Institute of Medicine's report in 1999.
The medical profession has made progress towards improving its culture of safety, being more transparent and redesigning systems to improve quality, but more needs to be done, he said. He also advocated for comprehensive health reform.
Pressure ulcers
Denise Nix, R.N., M.S., C.W.O.C.N., clinical practice specialist, Park Nicollet Health Services, Minneapolis; Melissa Marshall, Institute for Clinical Systems Improvement, Bloomington, MN and Debra Perry, nurse manager, Medical/Surgical, Olmsted Medical Center, Rochester, discussed best practices in pressure ulcer prevention and treatment.
Patient safety and the media
Ryan Davenport, system manager, media relations Fairview Health Services, Minneapolis, MN, Jeremy Olson, Pioneer Press, St. Paul, MN, and Walt Parker, vice president, Weber Shandwick, Bloomington, MN, discussed strategies the current environment between reporters and hospitals and strategies that providers can use to mitigate bad news and promote the coverage of good news.
Rural safety culture
Richard Nordahl, administrator/CEO, Sanford Westbrook Medical Center, Westbrook, MN and Ruth Opsata, R.N., Performance Improvement/Joint Commission Coordinator, Sanford Hospital Luverne, Luverne, MN, were part of a panel discussing how small, rural hospitals have implemented efforts to better understand the safety culture of their facilities.
Teaching patient safety
Barbara Brandt, assistant vice president, University of Minnesota – Academic Health Center, Minneapolis, discussed the Academic Health Center’s efforts to build patient safety awareness and principles into its health-care curriculum.
Transition coaches
Eric Coleman, M.D., University of Colorado Health Science Center, Aurora, CO, discussed transition coaches and provided participants with the core elements of the transition coach model that has been implemented in over 100 leading health-care organizations nationwide.
Coleman said the research has shown that the transition care model reduces hospital readmissions and results in significant savings. He also said that transition care measures have been developed and are gaining support in states and at the Centers for Medicare and Medicaid Services. To learn more, visit Coleman’s Web site at www.caretransitions.org.
Wrong site surgery
Kathleen Harder, Ph.D., director, Human Factors Research and Design, Minneapolis and Carol Hamlin, RN, MSN, director, Departmental Performance, University of Minnesota Medical Center, Fairview, Minneapolis, described the medical center's journey to eliminate wrong site surgeries.
Here is a list of the presentations at the conference by topic.
Accelerating improvement
Susan Nelson, R.N., director, project consulting group, and Craig Svensen, M.D., chief medical quality officer, HealthEast Care System, St. Paul, MN, described how HealthEast applied the accelerated improvement model to prevent venous thromboembolism.
Adverse health events
Julie Apold, director, patient safety, Minnesota Hospital Association, St. Paul, MN and Diane Rydrych, assistant director, division of Health Policy, Minnesota Department of Health, St. Paul, MN, discussed Minnesota’s adverse events reporting law, which was approaching its five-year anniversary. They shared key findings and strategies for reducing adverse events.
Clinic safety
Patrick Courneya, M.D., associate medical director, HealthPartners, Inc., Minneapolis, MN, spoke about HealthPartners efforts to develop methods to reduce adverse events and near misses in ambulatory care setting. Courneya discussed the "Ambulatory Patient Safety Toolkit" that HealthPartners developed in 2007 and updated in October. The toolkit includes safety protocols, guidelines, forms, and topic areas that clinics should focus on. The kit is available at http://www.healthpartners.com/files/34649.pdf.
Complexity compression
Patty Koenig, R.N., B.S.N., staff nurse and Kathie Krichbaum, Ph.D., R.N., associate professor, University of Minnesota School of Nursing, Minneapolis, MN, focused on the phenomenon of "complexity compression" that has been described and validated by groups of nurses at the point of care.
Communicating lab results
Tery Murray, quality coordinator, Quello Clinic, Bloomington, MN and Becky Rose, laboratory director, Quello Clinic, Minneapolis, MN, were part of a primary care team that took steps to improve the reliability and timeliness of laboratory results to patients.
Disclosing errors
Phillip M. Kibort, M.D., M.B.A, vice president, medical affairs, chief medical officer, Children’s Hospitals and Clinics of Minnesota, discussed Children’s policy to fully disclose adverse events to families including the barriers to disclosing such information and how Children’s overcame those barriers.
Electronic health records and care transitions
Jerome Siy, M.D., hospitalist and chief of professional services, and Julie Weegman, nurse manager, Oncology, Regions Hospital, St. Paul, MN, addressed how to keep the use of electronic medical records from resulting in communication breakdowns among providers.
Family advisory councils
Jim Conway, executive vice president/COO, Dana-Farber Cancer Institute, Boston, MA, discussed ideas for successful engagement of patients and their families and provided a forum to discuss barriers, success factors and strategies that might be helpful.
Health literacy
Bette-Jo Johnson, associate nurse manager, Park Nicollet Methodist Hospital, St. Louis Park, MN, discussed the relevance of health literacy to patient care, provided clinical tips for communicating effectively with patients, and discussed the relationship between health literacy and informed consent.
High reliability model
Karen Tucker, nurse manager, Cincinnati Childrens, Cincinnati, OH, discussed how one 24-bed general medical unit used high reliability concepts to sustain several outcomes, such as reducing codes, incorporating evidence-based care guidelines into practice, and reducing central venous catheter infections.
Human factors and safety
Thoralf M. Sundt III, M.D., Division of Cardiovascular Surgery, Mayo Clinic, Rochester, MN, discussed how human factors science -- how humans interact with products, procedures, processes and tools -– can help improve health care.
Sundt spoke about his own experiences as a surgeon and how the loss of a patient because of an air-bubble that was pumped into the patient’s brain during a heart transplant surgery profoundly affected him and led him to study error prevention and the field of human factors science.
Measuring safety
Barbara Balik, R.N., Ed.D., principal, Common Fire Healthcare Consulting, Albuquerque, NM and Trista Johnson, Ph.D., director of quality and outcomes, physician division, Providence Health and Services, Beaverton, OR, discussed the difficulties of developing useful, accurate and efficient safety measures.
MRSA infections
Noe Mateo, M.D., infection control medical director, and Stephanie Tismer, infection control practitioner, Regions Hospital, St. Paul, and Tom Michels, infection control practitioner, HealthPartners Inver Grove Heights Clinic, Inver Grove Heights, MN, discussed the challenges of preventing, detecting, and managing MRSA-colonized and infected patients in clinics, hospitals and nursing homes.
National overview
Lucian Leape, M.D., Harvard School of Public Health, in his presentation "The Patient Safety Journey" reviewed the state of patient safety in the United States since the release of the Institute of Medicine's report in 1999.
The medical profession has made progress towards improving its culture of safety, being more transparent and redesigning systems to improve quality, but more needs to be done, he said. He also advocated for comprehensive health reform.
Pressure ulcers
Denise Nix, R.N., M.S., C.W.O.C.N., clinical practice specialist, Park Nicollet Health Services, Minneapolis; Melissa Marshall, Institute for Clinical Systems Improvement, Bloomington, MN and Debra Perry, nurse manager, Medical/Surgical, Olmsted Medical Center, Rochester, discussed best practices in pressure ulcer prevention and treatment.
Patient safety and the media
Ryan Davenport, system manager, media relations Fairview Health Services, Minneapolis, MN, Jeremy Olson, Pioneer Press, St. Paul, MN, and Walt Parker, vice president, Weber Shandwick, Bloomington, MN, discussed strategies the current environment between reporters and hospitals and strategies that providers can use to mitigate bad news and promote the coverage of good news.
Rural safety culture
Richard Nordahl, administrator/CEO, Sanford Westbrook Medical Center, Westbrook, MN and Ruth Opsata, R.N., Performance Improvement/Joint Commission Coordinator, Sanford Hospital Luverne, Luverne, MN, were part of a panel discussing how small, rural hospitals have implemented efforts to better understand the safety culture of their facilities.
Teaching patient safety
Barbara Brandt, assistant vice president, University of Minnesota – Academic Health Center, Minneapolis, discussed the Academic Health Center’s efforts to build patient safety awareness and principles into its health-care curriculum.
Transition coaches
Eric Coleman, M.D., University of Colorado Health Science Center, Aurora, CO, discussed transition coaches and provided participants with the core elements of the transition coach model that has been implemented in over 100 leading health-care organizations nationwide.
Coleman said the research has shown that the transition care model reduces hospital readmissions and results in significant savings. He also said that transition care measures have been developed and are gaining support in states and at the Centers for Medicare and Medicaid Services. To learn more, visit Coleman’s Web site at www.caretransitions.org.
Wrong site surgery
Kathleen Harder, Ph.D., director, Human Factors Research and Design, Minneapolis and Carol Hamlin, RN, MSN, director, Departmental Performance, University of Minnesota Medical Center, Fairview, Minneapolis, described the medical center's journey to eliminate wrong site surgeries.
|
