2021 Patient Safety and Quality Symposium

Welcome
Andy Carter, President and Chief Executive Order, The Hospital and Healthsystem Association of Pennsylvania
 

Leveraging Models from Patient-Safety Efforts to Increase Equity
Ronald Wyatt, MD, MHA Vice President and Patient Safety Officer, MCIC Vermont, LLC
Member, Institute for Healthcare Improvement (IHI) Equity Advisory Group
Faculty member, IHI Pursuing Equity Initiative

There is no such thing as high-quality, safe care that is inequitable. Inequity in health care is a systems-based problem that requires a systems-based approach. The good news is that there is a natural alignment between the framework we use to improve safety and the approach we can take to increase equity. Both frameworks encourage redesigning systems to make them more reliable and resilient. During this session, we'll explore how our quality and safety infrastructure is critical to advancing equity in health care.
 

Case Study in Safety, Quality, and Equity
Esteban Gershanik, MD, MPH, MMSc, FAAP, FHM, Medical Director of Quality, Safety, and Equity, Brigham Health
Nadia Huancahuari, MD, Director of Safety and Equity, Brigham Health

Your health should not depend on where you were born, where you live or your economic status. Much like our hospitals across the Commonwealth−Brigham Health in Boston, Massachusetts remains committed to advancing systems of care, research, and community programs that elevate the health status of the communities. Hear how they addressed real life issues that affected health outcomes among the diverse population and how they created a state where—without question or exception—every single patient receives the same level of safe, high-quality care. This means that, in every patient encounter, safety and quality outcomes are considered a direct reflection of equitable care delivery.
 

Returning to the New “Normal”: Life after COVID-19
Moderator
Rob Shipp, III, PhD, BSN, RN, NEA-BC, Vice President, Population Health and Clinical Affairs, The Hospital and Healthsystem Association of Pennsylvania 
Panelists
Delinda Pendleton, RN, MSN, CPHQ, CPXP, FPCC, Director Patient Experience & Strategic Clinical Initiatives, Fox Chase Cancer Center
Linda Gangai, MSN, RN, CPHQ, CPPS, CMS, Manager Quality Improvement & Patient Safety, Department of Emergency Medicine, Penn State Health-Milton S. Hershey Medical Center
Ashley Visco, MSW, LCSW, CCM, Community Health Director, Penn State Health
Michelle Michaelis, BA, CPXP, Manager Patient Experience, Section 504 Disability Coordinator, UPMC Passavant

During the past few months, we have begun to see encouraging signs of a possible return to “normal,” with declining COVID-19 case counts and 75 percent of Pennsylvanians 18 and older having received at least one dose of the COVID-19 vaccine. In health care, we frequently tackle difficult challenges, and then rise up to face new ones as they emerge. Even though we appear to be leaving behind the worst of the COVID-10 pandemic, we must be cognizant of the continued threat of this health care emergency. Making plans to enter a new “normal” of life after COVID-19 provides us with the opportunity to bring with us lessons learned, opportunities for improvement, recovery strategies, and the ability to move forward with a renewed commitment to providing safe, high-quality patient care. Hear various perspectives from Pennsylvania health care leaders impacted by COVID-19 as they discuss the challenges faced during the pandemic, including emergency response, community outreach, and stories of health care provider and staff resiliency and bravery. 
 

Break
 

Regulatory and Accreditation Update

Patricia Conway-Morana, PhD, RN, CJCP, CPHQ, NEA-BC, CENP, RNC-OB, FACHE, Director, Continuous Service Readiness (CSR), RPI Certified Yellow Belt, Joint Commission Resource

Susan Coble, Deputy Secretary of Quality Assurance, Department of Health, Commonwealth of Pennsylvania

R. Scott Mincemoyer, RN, MSN, Bureau Director, Community Program Licensure and Certification, Department of Health, Commonwealth of Pennsylvania

Get the most up-to-date information from the Pennsylvania Department of Health (DOH) and the Joint Commission (TJC) to ensure your hospital is in compliance with Medicare Conditions of Participation (COPs), state licensure regulations, and accreditation standards. During this session, you’ll gain an understanding of what Centers for Medicare and Medicaid Service (CMS) waivers are still active and which are ending, with a focus on what hospitals can and can’t do going forward. You’ll also hear updates on recent CMS COP guidance and DOH survey activity. New and critical Joint Commission standards and initiatives for 2021–2022 will also be reviewed including: infection control, environment of care, emergency management, workplace violence prevention standards, and TJC’s safety advisory on understanding diverse populations.

Networking Lunch
 

Adjourn
 

Coffee Networking Session

Break
 

Day 2 Welcome
 

The Journey to Patient Safety: 20 Years After “To Err Is Human”
Mike Eisenberg, Director, To Err Is Human, A Patient Safety Documentary

Medical errors are the third leading cause of death in the United States, with 220,000 to 440,000 people dying each year from preventable errors. The landmark report, “To Err is Human,” first brought national attention to these preventable medical errors and the associated harm. The publication sparked a new focus on patient safety, quality of care and preventable adverse events. Now, 20 years later, we can reflect on the progress that has been made so far, including the impact of developing a culture of safety in health care organizations and the value of sharing medical errors to help others learn from those mistakes. Join Mike Eisenberg, director of the documentary “To Err is Human,” as he shares reflections on the original report through his documentary and interviews with national safety advocates.
 

Break
 

Interactive Breakout Sessions

After Action Review: Critical Analysis of Your Hospital’s COVID-19 Response

Chris Chamberlain, MS, RN, CHEP, Vice President, Emergency Management, The Hospital and Healthsystem Association of Pennsylvania

Ryan Weaver MBA, BSN, RN, CPPS, Manager, Emergency Management, The Hospital and Healthsystem Association of Pennsylvania

This session will discuss after action reporting and improvement planning related to the COVID-19 response. Using standard processes, the attendee will discover methods to gather, review, analyze, and track performance improvements, leading to better preparedness for the “next” emergency.

Escape Room: Reducing Latent Safety Errors and Improving Patient Safety

Therese Justus, RN, MSN, DNP, CEN, TNCC, System Director of Simulation Education, Allegheny Health Network

Virtual escape room experiences are a fun and novel way to engage teams in learning about teamwork and communication skills. By working together on interactive and challenging puzzles, virtual escape rooms level the hierarchy commonly found in clinical training and simulation environments. This presentation will showcase a proactive, comprehensive simulation session with multiple modalities of teaching to reduce patient safety errors. Participants will be immersed into both a virtual and hands on experience and receive tools to assess the clinical environment for latent safety errors. At the completion of this session, you will be able to create a patient safety escape room, address gaps in best practices through auditing and data analysis.

Success with Sepsis: Remote Patient Monitoring and Interventions

Angie Mays, Clinical Coordinator, Central Monitoring Services, WellSpan Health

Holly Wolfe, MBA, CPHQ, Senior Director of Quality, WellSpan Health

Erica K. Martin, MSN, RN, NE-BC, Program Director, WellSpan Health Medicine Service Line

Unacceptably high sepsis mortality rates and low bundle compliance compelled WellSpan Health (WSH) to develop a novel model of care to improve performance in a cost-effective way that leveraged rather than burdened clinician humanity. The Central Alert Team model of care combines electronic tools with the expertise of a remote, RN-staffed telemonitoring team to allow for early identification of sepsis, timely initiation of evidence-based treatment and standard work, ongoing monitoring for completion of bundle components, and positive patient clinical response. As a result, WSH has achieved statistically and clinically significant improvements in sepsis bundle compliance and mortality, saving the lives of more than 350 people with a principle diagnosis of sepsis in the past three years. The model’s process, procedure, workflow, reporting, and accountability structure/framework will be shared—for application to not just sepsis but other clinical conditions as well.

Maintaining Quality During a Pandemic

Christopher Huot, MSN, RN, CNML, Nurse Manager, Interim Clinical Director for Critical Care, Penn Medicine, Pennsylvania Hospital

Ida Macri, Infection Preventionist, Pennsylvania Hospital

The COVID-19 pandemic brought unprecedented challenges to hospitals across the state. One of these challenges was how to maintain high quality standards and metrics in the midst of crisis and process changes. This presentation will explore the impact of the pandemic on quality metrics in the critical care units at Pennsylvania Hospital. It will also focus on the work ahead to achieve high quality outcomes as normal operations are resumed.

Break
 

Making the Connection: Patient and Family Engagement as a Quality and Safety Improvement Strategy
Tom Workman, Senior Researcher, American Institutes for Research (AIR)

Hospitals across the United States are seeing the benefits of engaging patients and family caregivers as partners in efforts to reduce all-cause harms and improve patient-centered care. This presentation will review patient and family engagement best practices and how they can be applied directly to harm reduction in the hospital. The goal of the session is to help participants apply patient and family engagement in their efforts to improve quality and safety.