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National Patient Safety Foundation, the Renaissance Washington, DC Hotel, 999 9th Street N.W., Washington, DC 20001
03/12/2003-03/15/2003
Wednesday, March 12 8:00am-5:00pm NPSF Board Meeting 8:00am-4:30pm Institute for Healthcare Improvement (IHI) Minicourses 6:00pm-8:00pm Welcome Reception Thursday, March 13 7:00am-8:00am Continental Breakfast 8:00am-8:30am Congress Overview & Welcome Susan Edgman-Levitan, PA William F. Jessee, MD, CMPE 8:30am-9:30am Keynote - A View from the Top: The Role of Government in Improving Patient Safety Honorable Tommy Thompson Secretary, Department of Health and Human Services Secretary Thompson will outline the critical leadership role that is being played by the Federal government to improve patient safety throughout the US health care system. He will discuss Federal legislative, regulatory, research and technical assistance initiatives that are designed to help physicians, providers and patients enhance the safety of health care. 9:30am-10:00am Break/Exhibitors 10:00am-Noon Breakout Sessions:T101 Health Plan Track An Overview of Health Plan Involvement in Safety Philip Boulter, MD, Senior Vice President and Chief Medical Officer, Tufts Health Plan, Boston, MA T102 Hospitals and Nursing Track Can You Hear Me Now? Strategies to Improve High Risk Communications Michael Leonard, MD, Director of Patient Safety, Colorado Permanente Medical Group, Kaiser Permanente, Denver, CO Paul Preston, MD, Staff Anesthesiologist and Assistant Chief of Quality, Kaiser Permanente Medical Center, San Francisco, CA Chuck Biddle, CRNA, PhD, Professor, Graduate Program in Anesthesia, Medical College of Virginia, Virginia Commonwealth University, Richmond, VA T103 Medical Groups and Ambulatory Care Track Avoiding Adverse Drug Events Involving Renally-Active Medications Theresa Manley, RN, BSN, MBA, Director of Clinical Operations, Palo Alto Medical Foundation, Palo Alto, CA Improving The Safety of Immunotherapy Through Failure Mode and Effect Analysis Sandra Johnson, RN, BSN, BA, Palo Alto Medical Foundation, Palo Alto, CA Stopping the Line –Implementation of a Patient Safety Alert System Cathie Furman, RN, MHA, Vice President, Quality and Compliance, Virginia Mason Medical Center, Seattle, WA Robert Caplan, MD, Medical Director of Quality, Virginia Mason Medical Center, Seattle, WA T104 Patient and Families Track When Everyone Has a Seat at the Table: How Voluntary State Coalitions Get Results Jennifer Dingman, PULSE of Colorado, Pueblo, CO Mark Levine, MD, Colorado Patient Safety Coalition, Denver, CO Paula Griswold, Massachusetts Coalition for the Prevention of Medical Errors, Burlington, MA Rachel Rowe, RN, Foundation for Healthy Communities, Concord, NH T105 Pharmaceutical and Device Manufacturers Track NAHIT: Advancing Standards for Improved Patient Safety Through Information Technology Interoperability John Combes, MD, Senior Medical Advisor, Hospital and Health Systems Association of Pennsylvania, Harrisburg, PA T106 Information Technology Track A Systematic Approach to Technology Assessment Charles R. Denham, MD, CEO, Texas Medical Institute of Technology, Austin, TX T107 Media Track "Meet the Press" :World Class Coaching to Work with the Media John J. Nance, JD, John Nance Productions, Seattle, WA T108 Employers/Workforce Track Through the Patient's Eyes: The Niagara Health Quality Coalition Initiatives Using NCR/Picker Data Bruce Boissonnault, Executive Director, Niagara Health Quality Coalition, Buffalo, NY T109 NPSF Research Track Understanding Errors in Emergency Departments: A Convergence Approach Robert Wears, MD, University of Florida, Jacksonville, FL Understanding and Improving Error Detection and Recovery in Simulated Acute Care Settings: Fixation vs.Adaptability Jenny Rudolph, PhD, Boston College, Chestnut Hill, MA Noon-1:30pm Lunch in Exhibit Hall Media and NPSF Board Lunch 1:30pm-3:30pm Breakout sessions: T201 Health Plan Track Rewarding Clinical Quality and Patient Safety Through Innovative Contracting and Incentive Strategies Robert C. McDonald, MD, MBA, FCCP, Medical Director, Health Care Management, Anthem Blue Cross and Blue Shield, Indianapolis, IN Paige R. Sipes-Metzler, DPA, Manager, Health Promotion, Regence Blue Cross Blue Shield of Oregon, Portland, OR T202 Hospitals and Nursing Track Success Stories from the Pittsburgh Regional Health Initiative:Prevention of Nosocomial Infections Peter Perreiah, BA, BS, Pittsburgh Regional Healthcare Initiative, Pittsburgh, PA Karen Wolk Feinstein, PhD, President Jewish Healthcare Foundation, Chair, Pittsburgh Regional Healthcare Initiative (PRHI) Pittsburgh, PA T203 Medical Groups and Ambulatory Care Track Electronic Prescribing in an Outpatient Environment Robert K. Gribble, MD, Medical Director, Quality Improvement, Marshfield Clinic, Marshfield, WI Thomas Berg, BS, Medication Project Director, Information Systems, Marshfield Clinic, Marshfield, WI Sentinal Events:Lessons Learned from RCA in the Ambulatory Setting Hugh P. Renier, MD, Vice President for Medical Affairs at St. Mary’s Medical Center and Associate Medical Director of St. Mary’s/Duluth Clinic Health System, Duluth, MN T204 Patient and Families Track Walk a Mile in My Shoes:Using Role Playing to Teach Medical Students and Residents About Disclosure Mark Graber, MD, FACP, Chief of Medicine, Northport Veterans Hospital, Long Island, NY Ilene Corina, PULSE of New York, Wantagh, NY T205 Pharmaceutical and Device Manufacturers Track Pathways for Medication Safety: Current Tools and Next Steps Lorri Zipperer, Cybrarian, Zipperer Project Management, Evanston, IL Kathleen Jennison Goonan, MD, Senior Scientist, Center for Health System Design & Evaluation, Institute for Health Policy, Massachusetts General Hospital Judy Smetzer, RN, BSN, Vice President, Institute for Safe Medication Practices, Huntington Valley, PA Elizabeth Summy, Executive Director, American Society for Healthcare Risk Management, Chicago, IL T206 Information Technology Track CPOE –State of the Art ...and Science David C. Classen, MD, MS, First Consulting Group, Salt Lake City, UT T207 Hospitals and Nursing Track Shortage or Safety Crisis? The Safety Case and the Business Case for Workforce Stability Thomas G. Olivo, CPCM, Success Profiles, Bozeman MT Tammy Jernigan, ARNP, CIC, MS, Director of Employee Health/Infection Control Department, Baptist Hospital, Pensacola, FL T208 Information Technology Track Bedside Scanning Technologies: Issues and Value Mark Neuenschwander, The Neuenschwander Company, Bellevue, WA T209 NPSF Research Track Serious Medication Errors: Evaluation of Prevention Strategies in Pediatrics Donald Goldmann, MD, Medical Director of Quality Improvement, Children's Hospital, Boston, MA Remote Analysis of the Surgical Environment: Measuring the Effect of Debriefing Attendings on Surgical Safety Factors James Forrest Calland, MD, University of Virginia Health System, Charlottesville, VA 3:30pm-4:00pm Break 4:00pm-5:00pm Plenary Session - The Burden of Harm Carol Haraden, PhD Vice President, Institute for Healthcare Improvement Roger Resar, MD, Agent of Tremendous Change, Global Innovation Seeker, Luther Midelfort Hospital - Mayo Health System 6:00pm-8:00pm Exhibitor Reception Friday, March 14 7:00am-8:30am F601 Senior Leaders' Breakfast Session CEOs, COOs, CMOs, CNOs and all senior leadership This session is intended for CEOs and Senior Executives who will share their ideas, opportunities, and challenges. Successful implementation of effective patient safety initiatives requires commitment from the top and alignment of all team members. This is often difficult to achieve and the CEO has critical challenges and unique perspectives. The setting will be informal and there will be an opportunity for pre-registered attendees to suggest discussion topics in advance of the session. 7:30am-8:30am Breakfast Roundtable Discussions Discussion Topics: - Disclosure/Non-punitive Reporting - Leadership Techniques - NPSF Patient & Family Advisory Council - Patient Councils - Focus Groups - Reporting Techniques for Adverse Events - JCAHO Standards - Medication-Use System Technology and Automation - Assessment Tools - Handling the Media - Root Cause, Failure Mode and Effects Analysis - Regional Coalitions - Independent Redundancy - Reconciliation - Measurement - Six Sigma 9:00am-11:00am Plenary Panel - Rekindling the Central Fire: Stories CAN Change Your Life Peter Pronovost, MD, PhD, Anesthesiology/Critical Care Medicine, The Johns Hopkins University School of Medicine Ms. Sorrel King Founder of the Josie King Safety Program, Johns Hopkins Hospital Jeff Selberg, President and CEO, Exempla Healthcare Mary E. Foley, MS, RN, Immediate Past President, American Nurses Association, NPSF Board Member Sarah E. Larry, BN, RN, James A. Haley VA Hospital, Tampa FL 11:00am-1:00pm Exhibits, Posters and Lunch 1:00pm-3:00pm BreakOut Sessions F301 Health Plan Track Plan Initiatives to Support Safe Medication Practices Paul Kaplan, MD, Chief Medical Officer, Blue Cross Blue Shield of Delaware, Wilmington, DE Minalkumar Patel, MD, MPH, Executive Medical Director, Blue Cross Blue Shield of New Jersey, Newark NJ F302 Hospitals and Nursing Track Healing Design:Redesigning Hospitals to Improve Safety John Reiling, MBA, MHA, President and CEO, St. Joseph Community Hospital of West Bend, West Bend, WI F303 Medical Groups and Ambulatory Care Track True Coordination of Care: How to Improve Outcomes, Safety and Patient Satisfaction Sanford R. Kurtz, MD, Chief Operating Officer, Lahey Clinic, Burlington, MA Michael Rosenblatt, MD, MPH, FACS, Chair, Quality Council, Lahey Clinic, Burlington, MA Maria Gray, MT (ASCP), Director, Quality and Safety, Lahey Clinic, Burlington, MA Reducing errors of omission for patients by leveraging existing information systems Ken Gross, MD, Virginia Mason Medical Center, Seattle, WA Kim Leatham, MD, Virginia Mason Medical Center, Seattle, WA A Comprehensive Anticoagulation Clinic Program Edward Gibbons, MD, Deputy Chief of Medicine for Cardiovascular Services, Virginia Mason Medical Center, Seattle, WA F304 Patient and Families Track To Err is Human, To Forgive is Divine – Why the Internal Neutral Succeeds Where Tort Reform Fails Carole Houk, Principal, Carole Houk Associates, Alexandria, VA Barbara I. Moidel, MA, Organizational Ombudsman/ Mediator, National Naval Medical Center, Bethesda, MD F305 Information Technology Track Developing a Migration Pathway for Technology Adoption Charles R. Denham, MD, CEO, Texas Medical Institute of Technology, Austin, TX F306 Cancelled F307 Employers/Workforce Track Hospital Care Leaps Forward in Tennessee Jerry Burgess, President and CEO, Healthcare 21 Business Coalition, Knoxville, TN Texas Hospital Checkup Marianne Fazen, PhD, Dallas-Fort Worth Business Group on Health, Dallas, TX F308 NPSF Research Track Every Picture Tells a Story: The Use of Video to Improve Safety Colin Mackenzie, MD, Professor and Director of the National Study Center for Trauma and EMS, Baltimore, MD Yan Xiao, PhD, Director of the Human Factors Research Laboratories, University of Maryland, Baltimore, MD Matt Weinger, MD, Professor of Anesthesiology, University of California at San Diego, San Diego, CA George Blike, MD, Associate Professor of Anesthesiology, Dartmouth School of Medicine, Hanover, NH 3:00pm-3:30pm Break 3:30pm-4:45pm Plenary Session Leaps of Safety: Does Public Accountability Spur Error Reduction? Suzanne Delbanco, PhD, Executive Director, The Leapfrog Group Reactor Panel: William Golden Gary S. Kaplan, MD, Chairman and CEO, Virginia Mason Medical Center Reed V. Tuckson, MD, Senior Vice President, UnitedHealth Group The Leapfrog Group has made quite a splash in the health care pond by bringing the influence of large purchasers to bear on important structural and process of care steps to enhance patient safety. In this session, the Executive Director of Leapfrog will discuss the why, what, and how of their "initial leaps" of safety in health care. Drs. Kaplan, Tuckson and Kizer will then discuss how these initiatives have affected, and will continue to affect, their own organizations' patient safety activities — at the level of a hospital, a health plan, and the National Quality Forum. 6:30pm Dinner & Capitol Steps Performance Saturday, March 15 7:30am-8:30am Breakfast Roundtable Discussions Discussion Topics: - Disclosure/Non-punitive Reporting - Leadership Techniques - NPSF Patient & Family Advisory Council - Patient Councils - Focus Groups - Reporting Techniques for Adverse Events - JCAHO Standards - Medication-Use System Technology and Automation - Assessment Tools - Handling the Media - Root Cause, Failure Mode and Effects Analysis - Regional Coalitions - Independent Redundancy - Reconciliation - Measurement - Six Sigma 9:00am-10:30am Breakout Sessions S401 Health Plan Track SCOPE: Safety Collaboratives in the Out-Patient Environment Greg Pawlson MD, MPH, Executive Vice-President for RADD, NCQA, Washington, DC Julie Sanderson-Austin, Vice President, Quality Management and Research, American Medical Group Association, Alexandria, VA S402 Hospitals and Nursing Track How to Spread Safety Innovations Through Your Organization Gail A. Nielsen, BSHCA, FAHRA, RTR, Iowa Health System, Des Moines, IA John Whittington, MD, OSF Healthcare System, Peoria, IL S403 Medical Groups and Ambulatory Care Track Walking, Talking and Measuring for Patient Safety Resulting Doug Bonacum, BS, MBA, Vice President, Safety Management, Kaiser Permanente, Oakland, CA John Brookey, MD, Assistant Associate Medical Director Southern California Permanente Medical Group, Pasadena, CA Jed Weissberg, MD, Associate Executive Director for Quality and Performance Improvement, The Permanente Federation, Kaiser Permanente, Oakland, CA S404 Patient and Families Track "Visitors" No More! Effective Strategies to Create Councils and Other Patient and Family Advisory Roles Beverley H. Johnson, CEO and President, Institute for Family-Centered Care, Bethesda, MD S405 Pharmaceutical and Device Manufacturers Track Examples of Successful Reductions in Medication Errors: How Data Can Make a Difference Diane Cousins, RPh, U S Pharmacopeia, Rockville, MD Robert Weber, RPh, FASHP, UPMC, Presbyterian and Shadyside Pharmacies, Pittsburgh, PA Ronald Nosek, LCDR, MSC, USN, Department of Defense Patient Safety Program, Falls Church, VA Thomas D. Bigley, RPh, Upper Valley Medical Center, Tory, OH David A. Kotzin, RPh, BS, MS, Director, Dept. of Pharmacy Services, Greater Baltimore Medical Center S406 Information Technology Track A Research Study into the Successful Use of Smart Infusion Pumps Mark Sullivan, PharmD, MBA, BCPS, Vanderbilt University Medical Center, Nashville, TN S407 Hospitals and Nursing Track HFMEA: The VA Proactive Risk Assessment Model or How To Save the World Without Even Trying Erik Stalhandske, MPP, MHSA, Program Manager, Department of Veterans Affairs, National Center for Patient Safety, Ann Arbor, MI Joseph M. DeRosier, PE, CSP, Program Manager, Department of Veterans Affairs, National Center for Patient Safety, Ann Arbor, MI S408 Employers/Workforce Track The Business Case for Safety and Quality: What Can our Databases Tell Us Steve Grossbart PhD, Vice President, Clinical Analytics, Premier Inc., Charlotte, NC Sanjaya Kumar, MD, MPH, Chief Medical Officer, Quantros S409 Patient Safety Leadership Fellowship Breaking the Code of Silence Della Ming Lin, MD, Executive Director, Continuing Medical Education, The Queen's Medical Center, Honolulu, HI Improving Patient Safety Through Executive Walkarounds Suzanne Graham, PhD, MA, RN, Director of Patient Safety, California Regions, Kaiser Permanente, Oakland, CA The Impact of Education Methodology in Patient Safety Jeffrey F. Driver, JD, MBA, Chief Risk Officer Beth Israel Deaconess Medical Center, Boston, MA Hans S. Kim, MD, MPH, Medical Director, Clinical Effectiveness Beth Israel Deaconess Medical Center, Boston, MA Patricia H. Folcarelli, MA, RN, Director of Professional Development, Beth Israel Deaconess Medical Center, Boston, MA 10:30am-11:00am Break 11:00am-12:15pm Closing Plenary What Can Healthcare Learn From Other Industries Paul O'Neill Former Chairman of Alcoa Paul O'Neill was Chairman of Alcoa, one of the nation’s largest aluminum manufacturers. While at Alcoa, his personal leadership and advocacy for a safe workplace led to phenomenal improvements in Alcoa's safety performance. O'Neill is a staunch advocate of the application of many of those same techniques, and essential leadership principles, to improving the safety of health care. He will discuss how health care may learn lessons from other industries in their efforts to improve the safety of our care. 12:15pm Adjourn
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