Patient Safety and Quality Symposium

Welcome 
Jennifer Jordan, Vice President, Regulatory Advocacy, The Hospital and Healthsystem Association of Pennsylvania
 

Behavioral Health Preconference Workshop
 

A Patient’s Perspective: Providing Better Care for Patients in Behavioral Health issues in Emergency Department
Moderator: Jennifer Jordan, Vice President, Regulatory Advocacy, The Hospital and Healthsystem Association of Pennsylvania
Lynn Cooper, Behavioral Health Policy Specialist, Pennsylvania Association of Area of Agencies on Aging, Inc.

Boarding of mental health and substance abuse patients in emergency rooms is one of the most vexing challenges at hospitals across the country. With a shortage of behavioral health inpatient beds in hospitals and mental health facilities, patients can spend days boarded in an emergency rooms awaiting placement in an inpatient setting. Hear perspectives from a former patient with lived experienced and learn how to provide better care, and keep patients comfortable while they are awaiting long-term services.  
 

Restraint Reduction and De-escalating Psychiatric Patients in the Emergency Room 
Moderator: Jennifer Jordan, Vice President, Regulatory Advocacy, The Hospital and Healthsystem Association of Pennsylvania
James Bryant, RN, DNP, CEN, CPEN, NEA-BC, Vice President Emergency Services, Centra
Lisa Carey, Director of Performance Excellence, Temple University Health System

Mental illness and substance abuse emergencies now account for one in every eight emergency department (ED) visits. Unfortunately, many emergency providers are not equipped with the right tools to manage patients who are tense, restless, uncooperative, and show other signs of agitation. This often to leads patients being sedated and restrained, which can delay recovery, increase the likelihood of admission, and prolong a hospital stay. During this session, you’ll learn how to stabilize individuals by verbally engaging patients and creating an environment of collaborative treatment in order to dramatically reduce the need for coercive measures.
 

A Case Study: Management of Behavioral Escalations in Ambulatory Care
Khoi Dang, MD, Departmental Patient Safety Officer, Primary Care, CHOP
Nina Foster, MSW, Improvement Advisor, Children’s Hospital of Philadelphia
Carl Wolfarth MA, LPC, ACS, Senior Manager, Department of Child and Adolescent and Behavioral Health, CHOP

Behavioral health crises are on the rise across the country. Many organizations have no standardized method in place to address the associated risk. To address these growing concerns and mitigate risk to patients and staff, a multidisciplinary team from across a pediatric hospital network developed a pathway to guide clinicians on how to recognize escalating behaviors, utilize available staff resources, and respond to escalations with a goal of increasing staff and visitor safety. 
 

Lunch (On your own)
 

Welcome
 

Achieving a Culture of Zero Violence in Healthcare
Brian Uridge, MPA, CPP, CHPA, CTM, Deputy Director DPSS, University of Michigan and Director of Michigan Medicine Security

The health care profession has become the most dangerous environment with regard to workplace violence, with 75 percent of all workplace occurring in the health care setting. Community-based security—focused on reducing both risk and anxiety through building trust, scenario-based training and technology—creates an environment where our health care community focuses on prevention, intervention, and response to workplace violence. Hear from workplace safety expert, Brian Uridge, who will teach you how to implement community policing-based security models focused on trust, transparency and training, security strategies such as firearms, laser and K-9 programs. During this hands-on session he will create law enforcement-based training scenarios designed for the healthcare and clinical environment to ensure patients, staff and visitors feel and are kept safe.
 

Practical Ways to Improve Workforce Safety: Achieving a Culture of Zero Harm Reactor Panel
Moderator: Brian Uridge, MPA, CPP, CHPA, CTM, Deputy Director DPSS, University of Michigan and Director of Michigan Medicine
Panelists:
Mike Huss, Vice President of Security, Allegheny Health Network
Wesley Light, Regional Director, Security and Emergency Management, Trinity Health Mid-Atlantic
Alan Lynch, CHPA-L, CHSP, CHEP, HEM, Network Director, Safety & Security, St. Luke’s University Health Network

Pennsylvania hospitals have unfortunately experienced the severe consequences of workplace violence, whether it be in working in dangerous environments, physical and psychological injury, or traumatization—making it make it more difficult for nurses, doctors and other clinical staff to provide quality patient care. Hear more from our expert panel of clinical leaders as they outline their workforce safety challenges and how Pennsylvania’s hospitals can best develop a workforce safety strategy to decrease violent interactions at health care facilities and the potential for adverse medical events.
 

Networking Break
 

How to Tackle the Crucial Task of Training for an Active Shooter 
Paul Sarnese, CHPA, MSE, MAS, CAPM, Assistant Vice President of Environmental Services, Security and Safety, Virtua Health, Inc.

Active shooter events are on the rise, and emergency management and security officials are increasingly tasked with ways to effectively and safely train hospital workers on how to respond. Paul Sarnese will discuss the methodology of how to tackle the crucial task of training each hospital staff member and department, based on their unique functions within the hospital, as well as with their specific locations on any hospital campus.
 

Crisis Standards of Care
Moderator: Chris Chamberlain, MS, RN, CHEP, Vice President, Emergency Management, The Hospital and Healthsystem Association of Pennsylvania
Panelists:
David Oxman, MD, FACP, Associate Professor of Medicine, Division of Pulmonary, Allergy and Critical Care Medicine, Jane & Leonard Korman Respiratory Institute, Thomas Jefferson University Hospital & Sidney Kimmel Medical College 
Herbert Schiffer, DO, Emergency Physician, Medical Director, TowerDIRECT

Crisis standards of care are perhaps the most difficult topic to plan for in any setting. What is a hospital supposed to do when there are not enough resources to go around in a disaster? How do you have these conversations? Who should be involved? The first answer: everyone. Consensus is key, and paramount. Please join us and learn how physicians, bioethicists, communications specialists, and disaster planners to work through this incredibly arduous topic, including developing your triage teams and who is on them.
 

Adjourn
 

Networking Reception
 

Registration/Continental Breakfast/Networking/Exhibits
 

Lessons Learned about Human Fallibility, System Design, and Justice in the Aftermath of a Fatal Medication Error
Barbara Olson, MS, RN, CPPS, FISMP, Senior Advisor, The Just Culture Company
Reactor Panel:
Walter “Chip” Harrison, Senior Director, Quality & Safety, St. Luke’s University Health Network
Kelly Romano, Director of Infection Control and Patient Safety, Einstein Medical Center Montgomery 
Chatón T. Turner, Esq. Senior Associate Counsel and Vice President Risk Management/Disabilities Services, UPMC

Are you troubled by the criminalization of a medical error that recently occurred within a present-day health care organization? The guilty verdict in the recent trial of a nurse following the death of patient after a medication error has prompted debate about the role and accountability of health systems for analyzing, responding to, and supporting patients, families, and their workforce in the aftermath of harm. How do we come to the right conclusions about accountability? Are you looking for ways to prevent similar events from occurring in your own organization? Learn from 
Barbara Olson, Senior Advisor at the Just Culture Company, and a panel of experts about common, yet often unresolved system vulnerabilities, as well as key strategies and priorities needed to advance your organization's safety journey. 
 

Networking Break and Move to Breakout Session #1
 

Breakout Sessions 1
A. Front Door Approach to Decreasing Left Without Being Seen Rates
Faith Colen, MSN, RN, CEN, CPHQ, NEA-BC, Director, Quality and Patient Safety, UPMC St. Margaret

Hospital capacity, post-acute care, and staffing vacancy have severely impacted throughput in emergency departments (ED). Left Without Being Seen (LWBS) is a quality indicator for the performance of throughput within the ED. A patient who presents to the ED and leaves without being seen is at increased risk of poor outcomes. Using quality improvement techniques, nurse leaders in collaboration with physicians and ancillary department leaders are changing processes reducing LWBS. Using a structured quality improvement approach can positively impact patient outcomes and experience while avoiding loss to departmental and hospital revenue.

B. Novel Approach to Utilizing Predictive Analytics to Optimize Care Management
Kara Harris, Nurse Case Manager, Children's Hospital of Philadelphia
Annique Hogan, Medical Director of Care Management, Children's Hospital of Philadelphia
Noelle Stack, Nurse Manager for Care Management, Children's Hospital of Philadelphia

The transition from hospital to home for NICU patients requires immense planning by a multidisciplinary team, ensuring appropriate resources are in place and gaps in care are minimized that may result in a readmission to the hospital. Historically, there has not been a standardized way of connecting NICU patients with care management services post-discharge. This presentation will provide an overview of the care management model, a quality improvement summary of the tools and operational plan implemented, an overview of the customized predictive analytics tool developed, and the multidisciplinary perspectives of roles involved in the operational plan. The presenters will share lessons learned and best practices for enhanced outreach between inpatient departments and ambulatory care management supports.re Management, Children's Hospital of Pennsylvania.
 

Move to Breakout Sessions #2
 

Breakout Sessions #2

A. Readmission Huddles as an Efficient Means for Summarizing Performance and Ongoing Monitoring Target Patient Populations
Jack Faricelli, Master Improvement Advisor, Pennsylvania Hospital

This session will provide a top down view of our implementation and evolution of a readmission huddle. The establishment of team goals aimed at monitoring readmissions created a need for a forum to gather, review data overtime, identify data signals, discuss insights and possible improvement opportunities. The key huddle features included short meetings with participants gathering around statistical control charts annotated with key takeaways and discussed for a number of distinct patient populations prior pandemic. Within the pandemic, the meetings evolved into a virtual meeting. Examples of charts, participating roles, data sources, and meeting format will be described. In addition to questions and answers, we invite session participants to describe their efforts.

B. Employee Injury and Event Review and Support Program
Camellia Herisko, Vice President of Operations and Patient Care Services and Chief Nursing Officer, UPMC Western Psychiatric Hospital and Western Behavioral Health
Jeff Magill, Manager, Clinical Services, UPMC Western Psychiatric Hospital and Western Behavioral Health
Joe Zimmerman, Director, Quality and Patient Safety, UPMC Western Psychiatric Hospital

This presentation will review the current staff incident review process that was implemented at UPMC Western Psychiatric Hospital to provide a system of analysis related to these staff episodes. A staff injury or aggressive act toward a staff in the behavioral health setting is when staff are injured and or physically touched by a patient in an act of physical aggression regardless if an injury occurs. These situations can cause significant harm to a staff member or may have resulted in a near miss. There may also be emotional injury experienced by the employee. These episodes effect staff retention negatively. Analysis of these events regardless of the level of injury is completed on a weekly basis in a Root Cause Analysis or event review.
 

Move to Breakout Session #3
 

Breakout Sessions #3
A. Best Practices in Crisis Staffing
Sherry Kolb, RN, President Emeritus, Qualivis

Now, more than ever, hospitals across the country have experienced firsthand the importance of using dependable staffing partners to help bridge the gap and provide expedited staffing. By utilizing expedited staffing best practices, facilities can ensure they are able to fill roles and continue to best serve their patients with quality care. During this session, you’ll learn best practices for expedited orientation process and flexibility in start dates, virtual orientations and their application, truncated compliance approaches that work, clinical assessments—how to assess, review, and recommend the most qualified candidates based on specified preferences and hiring criteria.

B. Advancing Health Equity in Patient Safety
Eileen Jaskuta, MSHA, BSN, RN, System VP Quality and Patient Safety, Main Line Healthsystem 

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. During this session, Main Line Health leaders will discuss how their quality and safety infrastructure and strategic framework is critical to their efforts to advance equity, including: tactics to improve patient safety while concurrently eliminating inequities in health care and approaches to integrate equity improvement efforts with quality improvement priorities.
 

Move to Plenary Session
 

Preparedness and Your Supply Chain; Tools, Tips and Strategies To Align Preparedness Efforts with The Health Care Supply Chain
Joe Tibbs, President, HAPevolve

Disasters, pandemics, and other emergencies can bring forth so many unprecedented challenges in health care, including the worldwide demand for supplies. PPE becomes a scarcity with suppliers unable to fulfill the increased demand. Joe Tibbs, President of HAPevolve, will share how planning, preparedness, and training are the most effective tools in developing strategies to address supply disruptions, increase utilization to impact your ability to access needed supplies, communicate within your organization, and mitigate impacts of supply disruptions.
 

Lunch and Closing Session
 
Resilience and Courage through Chaos 
Erin Erb, MHA, RHIA, LSSBG, CPHQ, Division Vice President, Health Care Quality and Patient Safety, HCA Houston Health Care

Now, more than ever, health care leaders and frontline workers must be resilient. While most people want to be more resilient, many are running on empty and simply do not know how. Organizational and leadership support for providers during disasters or public health emergencies has a powerful impact on organizational resilience, patient safety, and staff retention. Through real-life examples ranging from weather disasters to pandemic response, this presentation will help participants identify approaches to build leadership and frontline workforce resilience in a no-nonsense and completely achievable way. You’ll leave this closing session inspired and energized to lead resilient teams!
 

Adjourn