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@theNPSF will be tweeting from Congress Use the hashtag #NPSF18 to join the conversation

Be sure to visit the Learning & Simulation Center in the KIERLAND GRAND BALLROOM, LEVEL 2

for Simulations, Exhibits, Posters, Receptions, Lunches, and Prize Drawings

DON’T MISS! Welcome Reception, Monday, 4:15PM–6:15PM Networking Reception, Tuesday, 4:15PM–6:15PM in the Learning & Simulation Center

National Patient Safety Foundation npsf.org/congress

SCHEDULE AT-A-GLANCE

For full program details, including session descriptions, faculty information, and specifics on continuing education, download our mobile app: NPSF Congress 2016.

Available in the iTunes Store and Google Play. Or check npsf.org/congress for session details and to download presentations.

May 23–25, 2016 • Scottsdale, Arizona

2 • NPSF PATIENT SAFETY CONGRESS 2016

MONDAY, MAY 23IMMERSION WORKSHOPS7:00 AM – 6:00 PMRegistration Open

HALL OF STATE, LEVEL 2

8:30 AM – 4:00 PM Certified Professional in Patient Safety (CPPS) Review Course

HERBERGER 4, LEVEL 1Karen Garvey, RN, BSN, MPA/HCA, CPHRM, CPPS, Vice President, Safety

and Clinical Risk Management, Parkland Hospital and Health SystemJohn B. Hertig, PharmD, MS, CPPS, Associate Director, Center for

Medication Safety Advancement, Purdue University College of Pharmacy

Regina Hoffman, RN, BSN, CPHRM, CPPS, Executive Director, Pennsylvania Patient Safety Authority

Mark Jarrett, MD, MBA, MS, CPPS, Chief Quality Officer, Senior Vice President and Associate Chief Medical Officer, Northwell Health; Professor of Medicine, Hofstra Northwell Health School of Medicine

Donna Jenkins, RN, MS, CPPS, Patient Safety Staff Specialist, Massachusetts General Hospital

Dot Snow, MPH, CPPS, CHIE, Quality Resource Management Director in National Resource Stewardship, Kaiser Permanente

This review course is being offered to experienced patient safety professionals who plan to take the Certified Professional in Patient Safety (CPPS) examination. This course can help participants prepare for the exam by reviewing domain content areas and test-taking strategies.

8:00 AM – 4:15 PMLeadership Day. High Reliability: Translating the Science into

the Heart and Art of Improving Patient and Workforce SafetyHERBERGER 5, LEVEL 1Ann Scott Blouin, RN, PhD, FACHE, Executive Vice President, Customer

Relations, The Joint Commission; Secretary, NPSF Board of Directors Gerry Castro, PhD, Patient Safety Director, The Joint CommissionErin DuPree, MD, FACOG, Vice President and CMO, The Center for

Transforming HealthcareAnn Hendrich, PhD, RN, FAAN, Senior Vice President, Chief Quality/Safety

and Nursing Officer, Ascension HealthErin Lawler, MS, Patient Safety Specialist and Human Factors Engineer,

Office of Quality and Patient Safety, The Joint CommissionStephen C. Swinney, MD, MBA, FACP, Chief Quality Officer, St. Vincent

Health, Indianapolis, IndianaCindy Williams, DNP, RN, MBA, FACHE, Senior Director, Care Excellence,

Ascension HealthRonald Wyatt, MD, MHA, DMS(HON), Patient Safety Officer, Medical

Director, Office of Quality and Patient Safety, The Joint Commission

This Leadership Day Immersion Workshop is designed to provide current and aspiring leaders in health care, including executives and C-suite leaders, governance teams, patient safety and quality professionals, and clinicians, with an understanding of how health care delivery organizations are successfully implementing high-reliability principles as an effective strategic framework for reducing error and harm to patients, families, and our health care workforce. Our expert faculty will guide participants on how the science of high reliability can be adapted into both the “heart and art” of your strategic and tactical commitments and initiatives to improve safety. Case examples and resources for getting started and advancing your high-reliability initiatives will be provided.

8:30 AM – 4:00 PMImplementing an Effective Communication and Resolution

Program to Improve SafetyGREENWAY, LEVEL 1Richard Boothman, JD, Chief Risk Officer, University of Michigan Health

SystemJeff Convissar, MD, Medical Director, Care Management Institute (CMI),

Kaiser PermanenteThomas Gallagher, MD, Professor and Associate Chair, Department of

Medicine, University of Washington Erin N. Grace, MHA, Director, Patient Safety Program, Center for Quality

Improvement and Patient Safety, Agency for Healthcare Research and Quality

Pat Folcarelli, RN, PhD, Director of Patient Safety & Health Care Quality, Beth Israel Deaconess Medical Center

Roxane Gardner, MD, MPH, DSc, Assistant Professor Ob/Gyn, Brigham and Women’s Hospital; Director of the Labor and Delivery Program, Center for Medical Simulation

Beth Daley Ullem, MBA, Board Member, Solutions for Patient Safety and The Center for Healthcare Value; Board of Advisors, NPSF; Former Board Member, Children’s Hospital of Wisconsin and Thedacare Center for Healthcare Value

Melinda B. Van Niel, MBA, CPHRM, Manager, Patient Safety, Department of Health Care Quality, Beth Israel Deaconess Medical Center

This session is presented in partnership with the Collaborative for Accountability and Improvement and NPSF.

Despite our best efforts as care providers, adverse events happen far too often. Most efforts to respond to them do not actively improve patient safety or meet the needs of patients and providers. Communication and resolution programs (CRPs) turn adverse events into opportunities for improvement. They ensure open communication after an adverse event is discovered, a comprehensive analysis of what happened with subsequent safety improvements, emotional support for patients and providers, and an appropriate resolution. At this workshop, health care leaders will learn how to implement CRPs effectively in their organizations.

Wireless Internet Access courtesy of Mallinckrodt Pharmaceuticals. Connect to: Mallinckrodt | Password: scottsdale2016

WELCOME TO THE HEART OF SAFETY18th Annual NPSF Patient Safety Congress

Program details are subject to change

NPSF PATIENT SAFETY CONGRESS 2016 • 3

8:30 AM – 4:00 PMPatient Safety Science: Successful Practices to Optimize Root

Cause AnalysisHERBERGER 2, LEVEL 1James P. Bagian, MD, PE, Director, Center for Healthcare Engineering

and Patient Safety, University of Michigan; Professor, University of Michigan Medical School and University of Michigan College of Engineering

Joseph M. DeRosier, PE, CSP, Program Manager at the Center for Healthcare Engineering and Patient Safety at the University of Michigan

This full-day course is designed for health care professionals who want to advance their knowledge base of root cause analysis concepts for practical application throughout their health care organization. In this session participants will learn new strategies to optimize the effectiveness of the root cause analysis (RCA) process, based on an NPSF expert panel’s recommendations.

4:15 PM – 6:15 PM

LEARNING & SIMULATION CENTER – Opening Reception, Simulations, Exhibits, Posters, Prize DrawingsKIERLAND GRAND BALLROOM, LEVEL 2

SIMULATIONS4:30 PM – 5:00 PM Simulation 1: The Heart, It Matters:

A Cardiac Event BOOTH 211

5:00 PM – 5:30 PM Simulation 2: The Heart of the Matter: Using Simulation During a Root Cause Analysis

BOOTH 417

5:30 PM – 6:00 PM Simulation 3: Heart to Hearts Matter: Communication and Resolution After an Event

BOOTH 711

6:15 PM – 8:00 PMNetworking Event for members of ASPPS, the Stand Up for

Patient Safety program, CPPS, and AHA Fellow Alumni (by invitation)

MARSHALL’S OUTPOST LAWN

TUESDAY, MAY 247:00 AM – 6:00 PMRegistration Open


8:00 AM – 9:30 AMKEYNOTE: The NPSF Lucian Leape Institute Presents: Teaming

at the Heart of Safety TRAILBLAZERS BALLROOM, LEVEL 2Amy C. Edmondson, PhD, AM, Novartis Professor of Leadership and

Management, Harvard Business SchoolWith panel members: Susan Edgman-Levitan, PA, Executive Director, John D. Stoeckle Center

for Primary Care Innovation, Massachusetts General HospitalGary S. Kaplan, MD, FACMPE, Chair, NPSF Lucian Leape Institute,

Chairman and CEO, Virginia Mason Health SystemRobert M. Wachter, MD, Interim Chair, Department of Medicine,

University of California San Francisco

Continuous improvement, understanding complex systems, and promoting innovation are all part of the landscape of learning challenges today’s companies face. Organizations thrive, or fail to thrive, based on how well the small groups within those organizations work. In most organizations, the work that produces value for customers is carried out by teams, and increasingly, by flexible team-like entities. The pace of change and the fluidity of most work structures means that it is not really about creating effective teams anymore, but instead about leading effective teaming, including teams within leadership. Teaming shows that organizations learn when the flexible, fluid collaborations they encompass are able to learn. The problem is teams, and other dynamic groups, don’t learn naturally. In this session Prof. Edmondson will outline the factors that prevent them from doing so, such as interpersonal fear, irrational beliefs about failure, groupthink, problematic power dynamics, and information hoarding. With teaming, leaders can shape these factors by encouraging reflection, creating psychological safety, and overcoming defensive interpersonal dynamics that inhibit the sharing of ideas.

9:45 AM – 10:45 AMCONCURRENT BREAKOUT SESSIONS

Track 1: Advancing Safety Science Implementation101: Implementation of a Strategic Approach to High

Reliability at the Sharp EndHERBERGER 1, LEVEL 1Jennifer Carpenter, RHIA, CPPS, Senior Patient Safety Consultant,

Advocate Health CareKate Kovich, MS, OT, CPPS, Vice President, Patient Safety, Advocate

Health CareRachel Zastrow, RN, MSN, CPPS, Director of Patient Safety, Advocate

Health Care

This session will briefly describe implementation of a strategic approach to high-reliability health care. Key implementation strategies will be reviewed along with how the strategies have been connected and reinforced throughout the system. The program will conclude with lessons learned and outcomes from the High Reliability Unit (HRU) along with the broader strategic plan.

Track 2: Creating a Culture of Safety in the Workplace102: Peer-to-Peer Interprofessional Mentoring: Impacting

Attitudes of Nurse-Physician CollaborationHERBERGER 2, LEVEL 1Stephen Daniel DeMeo, DO, Fellow, Neonatal-Perinatal Medicine, Duke

University Health SystemPamela B. Edwards, EdD, MSN, RN-BC, CNE, CENP, Associate Chief Nursing

Officer, Education, Duke University Health System

Don’t miss the raffle drawings for prizes, at the NPSF booth in the Learning & Simulation Center:

Monday 6:00PM Tuesday 1:00PM and 6:00PM

Wednesday 1:00PM



Interprofessional collaboration is essential to patient safety yet is often difficult to accomplish in a real-world setting. Health care professionals such as physicians and nurses have been socialized into hierarchical rather than collaborative working relationships through formal academic preparation. This session will detail a program that supported interprofessional collaboration and peer–to-peer mentoring across groups of 30 nurse residents / resident physicians. Participants will examine the program construction, outcomes of the joint projects, and lessons learned in order to replicate similar programs across health care settings.

Track 3: In Safe Hands: Providing Safe Care for Kids…Even if You’re Not a Specialist

103: Patient and Family Shadowing: A Safety SolutionGREENWAY, LEVEL 1Michelle L. Bulger, Patient and Family Centered Care (PFCC) Conference

Coordinator, PFCC Innovation Center of University of Pittsburgh Medical Center

This session will discuss Patient and Family Shadowing as a real-time tool that allows any care team member to identify improvement opportunities in safety and the patient experience, by following the patient and family through their health care journey to determine challenges and needs and hear the patient’s voice in addressing them. Improvement projects are then generated and the solutions are co-designed with patients and families. Participants will be given a shadowing journal to capture their observations during the simulation and a shadowing report template to guide them in generating a report out. These tools are also free and downloadable on our website, pfcc.org, for participants to access back at their facilities.

Track 4: Optimizing the Benefits and Minimizing the Harm of Health Technology

104: Partnering for Action: The Partnership for Health IT Patient SafetyHERBERGER 4, LEVEL 1Mary Beth Navarra-Sirio, RN, MBA, Vice Chair, NPSF Board of Directors,

former Vice President and Patient Safety Officer, McKesson Corporation

Lorraine Possanza, DPM, JD, MBE, Senior Patient Safety, Risk, and Quality Analyst, and HIT Safety Liaison, ECRI Institute

Ronni P. Solomon, Esq., Executive Vice President and General Counsel, ECRI Institute

This session presents findings and best practices from the Partnership for Health IT Patient Safety, a multistakeholder collaborative whose purpose is to make health information technology (HIT) safer together. An expert panel from the Partnership will discuss learnings and interventions to prevent HIT-related hazards and adverse events that cause injury to patients and undermine an organization’s reputation. Emphasis will be placed on high-priority issues, and ways to eliminate safety barriers.

Track 5: Patient Safety Beyond the Walls of the Hospital105: Utilizing a PSO to Decrease Diagnostic Error

HERBERGER 5, LEVEL 1Helga Brake, PharmD, CPHQ, CPPS, Director, Midwest Alliance for Patient

Safety PSOBrenda Schmitz, MS, RN, CRN, Clinical Practice Consultant, Northwestern

Memorial Hospital

This session will provide information on the benefits of being a Patient Safety Organization (PSO) member, how to foster reporting when diagnostic error is involved, and how Safe Table discussion can optimize sharing and learning among health care providers in all settings. This session will examine the development, implementation, and spread of a technology solution to streamline the identification and communication of unexpected radiologic findings to referring physicians to decrease the incidence of patient harm and potential compensatory events.

Track 6: Sizzling in Scottsdale: Hot Topics in Patient Safety106: Board Quality RX: Building a More Capable Board

Engaged on Quality and SafetyHERBERGER 3, LEVEL 1Beth Daley Ullem, MBA, Board Member, Solutions for Patient Safety and

The Center for Healthcare Value, Board of Advisors, NPSF, and Former Board Member, Children’s Hospital of Wisconsin and Thedacare Center for Healthcare Value

The Board of Directors is responsible for the oversight, leadership selection, and performance targets for your hospital. Yet, most boards still struggle to have a solid understanding of key safety and quality issues preferring to stay in their comfort zones of finance and development. The patient asks hospitals first to heal and not harm, not just make a profit. Most senior leaders of hospitals struggle to build a board more capable of engaging on quality and safety issues that are a priority to patients and critical to population health management going forward.

In this session, the presenter will highlight the challenges to creating a board of directors that is committed to and understanding of quality and safety. She will discuss how some institutions have created more engaged boards and supported the engagement of the board on quality and safety issues, as well as the variation across boards in covering key quality issues and the need to establish a standard of care for a board to cover on safety and quality. The presenter will also speak about board assessment approaches to identify content competency and not just motivation and strategies to build a board that is more competent and committed on quality and safety.

11:00 AM – 12:00 PMCONCURRENT BREAKOUT SESSIONS

Track 1: Advancing Safety Science Implementation201: Patient Safety and the Hidden Harm of Non-ventilator-

Hospital-Acquired PneumoniaHERBERGER 1, LEVEL 1Dian Baker, PHD, RN, Professor School of Nursing, California State

University SacramentoBarbara Quinn, RN, CNS, Clinical Nurse Specialist, Sutter Medical Center

This session will include a review of the most recent data on the pathophysiology, incidence, risk factors, prevention, and cost of

All Keynote Sessions take place in TRAILBLAZERS BALLROOM, LEVEL 2

Breakout Sessions are organized in six theme tracks.Session numbers ending in -01: Advancing Safety Science Implementation HERBERGER 1, LEVEL 1

Session numbers ending in -02: Creating a Culture of Safety in the Workplace HERBERGER 2, LEVEL 1

Session numbers ending in -03: In Safe Hands: Providing Safe Care for Kids GREENWAY, LEVEL 1

Session numbers ending in -04: Optimizing the Benefits and Minimizing the Harm of Health Technology HERBERGER 4, LEVEL 1

Session numbers ending in -05: Patient Safety Beyond the Walls of the Hospital HERBERGER 5, LEVEL 1

Session numbers ending in -06: Sizzling in Scottsdale: Hot Topics in Patient Safety HERBERGER 3, LEVEL 1


non-ventilator-hospital-acquired pneumonia (NV-HAP). The overview of our body of work will include: (1) a completed pilot study that included both incidence and intervention, which will be presented as a case study; (2) a multicenter study (24 US hospitals) undertaken specifically to improve our understanding of the US incidence of NV-HAP; and (3) a secondary analysis of the US NV-HAP incidence using the 2012 Healthcare Utilization Project (HCUP) dataset. These data sources, when taken together with other available data, will improve our understanding of the scope of the problem of NV-HAP in US hospitals and lay the groundwork for the need to implement prevention efforts and improve patient safety.

Track 2: Creating a Culture of Safety in the Workplace202: Addressing Co-Worker Reports of Unprofessional

BehaviorHERBERGER 2, LEVEL 1Roger R. Dmochowski, MD, CPPS, Executive Medical Director, Quality,

Safety, and Risk Prevention, Vanderbilt University Health SystemLynn E. Webb, PhD, Assistant Dean, School of Medicine, Center for Patient

and Professional Advocacy, Vanderbilt University Medical Center

This session describes the effective implementation of an organizational process to address co-worker reports of unprofessional conduct associated with physicians and advanced practice professionals. Participants will assess their organization’s readiness to implement a similar process.


203: Engaging Families, Delivering Safer CareGREENWAY, LEVEL 1Sarah Cawley, Family Lead, Family Engagement Committee, Cleveland

Clinic Amrit Gill, MD, FAAP, Patient Safety Officer, Cleveland Clinic Children’sShannon Phillips, MD, MPH, Associate Chief Quality Officer, Cleveland

Clinic

This session will discuss the tools for effectively implementing a patient and family advisory council and specifically how this engagement improves the quality and safety of care in the hospital.


204: Improving Patient Surveillance Reduces MortalityHERBERGER 4, LEVEL 1Thomas Donohue, Chief of the Medical Service, St. Raphael’s Campus,

Yale New Haven Hospital, Yale New Haven Health System

This session will describe how a combination of integrated, automated, acuity scoring tools and proactive nursing care yielded significant reductions in inpatient mortality. The session will include detailing model components, case histories, and what we learned in the process of workflow integration.

Track 5: Patient Safety Beyond the Walls of the Hospital205: Improving Medication Adherence through Motivational

Interviewing and Health LiteracyHERBERGER 5, LEVEL 1Corey Gregg, BA, MPH, Fourth-Year Medical Student, University of Miami

School of MedicineLoAnn Heuring, MD, Internal Medicine/Pediatrics Resident (PGY-4),

University of Miami/Jackson Health System

The objective of this interactive session is to increase awareness, enhance knowledge and skills, and improve self-confidence regarding the approach to medication non-adherence and overall patient behavior change. The session will go on to outline the implementation of an innovative Medication Adherence Clinic QI project, aimed to train residents to use motivational interviewing techniques and health literacy tools to improve medication adherence in at-risk patients. At the end of the session, we will provide preliminary data from our project and discuss the successes and challenges that we have faced during this pilot year.

Track 6: Sizzling in Scottsdale: Hot Topics in Patient Safety206: Reinvent the Wheel: Serious Event Analysis

HERBERGER 3, LEVEL 1Susan Lott, RN, BSN, MSA, Director, Patient Safety, Hospital Corporation

of AmericaRuth Westcott, AVP, Patient Safety, Hospital Corporation of America

This session will present the journey of the HCA’s Patient Safety Organization (PSO) from an inconsistent, paper-based methodology for conducting consistent root cause analysis (RCA) across the enterprise, to developing and successfully implementing a standardized framework for completing thorough and credible RCAs, renamed as Serious Event Analysis (SEA), across a large health system comprised of hospitals and ambulatory surgery centers. This process began with a 2013 organizational safety assessment, followed by 2014 alpha and beta pilots and 2015 organization rollout. The standardized SEA framework allows for uniform process application, data aggregation, comparative analysis, and meaningful, evidence-based practice solutions for improving patient safety.

12:00 PM – 1:30 PM

LEARNING & SIMULATION CENTER – Lunch, Simulations, Exhibits, Posters, Prize Drawings

KIERLAND GRAND BALLROOM, LEVEL 2




BOOTH 417


BOOTH 711

1:45 PM – 2:45 PMCONCURRENT BREAKOUT SESSIONS

Track 1: Advancing Safety Science Implementation301: Workplace Violence

HERBERGER 1, LEVEL 1Ann Scott Blouin, RN, PhD, FACHE, Executive Vice President, Customer

Relations, The Joint Commission, Certified Green BeltHala Helm, JD, MBA, CPHRM, CHC, FACHE, FASHRM, Chief Risk Officer,

Palo Alto Medical Foundation

This session is presented in partnership with ASHRM and NPSF.

Workplace violence is an increasing concern across all industries, including health care. Violence can occur in any setting, against any patient, visitor, or staff member. It can result in patient and staff injuries and even death. The speakers will present statistics on workplace violence, root causes, and correlations associated with violence and resources to assist health care organizations and their leaders to prevent, mitigate, and manage escalating situations that can lead to violence.

Track 2: Creating a Culture of Safety in the Workplace302: Implementing Principles of Integrated Leadership to

Have a Health Care System Free From HarmHERBERGER 2, LEVEL 1James Rohack, MD, FACC, FACP, Senior Advisor and Former President,

American Medical Association

This session will review the principles of integrated leadership for hospitals and health systems. Through the use of case scenarios, the learner will be able to enhance their knowledge on how principles are key to having the culture of trust that is needed to have a health care system free from harm.



303: Human Factors: Fixing Technology Risks to KidsGREENWAY, LEVEL 1A. Joy Rivera, PhD, Human Factors Systems Engineer in Informatics,

Children’s Hospital of WisconsinMatthew Scanlon, MD, CPPS, Professor of Pediatrics, Critical Care, Medical

College of Wisconsin; Human Factors and Systems Physician in Informatics, Children’s Hospital of Wisconsin

This session will explain the science of human factors engineering, then discuss its uses to find and fix technology problems that pose hazards to pediatric patients.


304: Make a Scan Plan: Barcode Optimization StrategiesHERBERGER 4, LEVEL 1Ruth Labardee, DNP(c), MSN, RNC, CNL, Manager, Nursing Quality and

Patient Safety, The Ohio State University Wexner Medical CenterJoe Melucci, MBA, RPh, Medication Safety Officer, The Ohio State

University Wexner Medical CenterDavid Nguyen, PharmD, BCPS, Clinical Pharmacy Specialist, Hospital

Sisters Health System St. Elizabeth’s HospitalMaggie Wong, PharmD, BCPS, Pharmacy Informaticist, Hospital Sisters

Health System

Barcode medication administration (BCMA) has been widely adopted and has consistently shown reduction in medication error rates and improved patient safety. However, implementation alone is insufficient to see the maximum safety benefits of BCMA technology. In this session, successful and reproducible strategies to optimize barcoding will be shared. Discussion surrounding the advantages of and barriers to barcoding will equip leaders with information to consider the applicability of the technology.

Track 5: Patient Safety Beyond the Walls of the Hospital305: Developing a Patient Safety Program Across the

ContinuumHERBERGER 5, LEVEL 1Timothy Bowers, MT(ASCP) MS CIC, Director, Infection Prevention and

Outpatient Quality, Inspira Health Network

The session will highlight a network approach to patient safety in the outpatient areas from conception to present status as one way to improve the safety of our patients, employees, and community.

Track 6: Sizzling in Scottsdale: Hot Topics in Patient Safety306: DEA Drug Trends

HERBERGER 3, LEVEL 1Thomas W. Prevoznik, Unit Chief, Liaison and Policy Section, Office of

Diversion Control, US Drug Enforcement Agency

New regulations and activities in the US Drug Enforcement Administration have an important influence on patient safety. This session will bring attendees up to date on their role in helping to curb the problem of prescription drug abuse, identifying common “red flags” regarding errant prescribing, and recognizing forgeries and recipient drug-seeking behavior, as well as details regarding the rescheduling of hydrocodone and much more.

3:00 PM – 4:15 PMKEYNOTE: Shared Decision Making and Patient Safety: Making

the Connections in Clinical PracticeTRAILBLAZERS BALLROOM, LEVEL 2Benjamin W. Moulton, JD, MPH, Senior Vice President, Informed Medical

Decisions Foundation, Advocacy and PolicyKaren Sepucha, PhD, Director, Health Decision Sciences Center, General

Medicine Division, Massachusetts General Hospital; Assistant Professor of Medicine, Harvard Medical School

Leigh Simmons, MD, Internal Medicine Physician, Massachusetts General Hospital

Patricia J. Skolnik, Founder and Executive Director, Citizens for Patient Safety

Shared decision making (SDM) is a collaborative process that allows patients and their providers to make health care decisions together, taking into account the best scientific evidence available, as well as the patient’s values and preferences. But what happens when this collaboration does not take place, especially with vulnerable patients? And what happens when shared decision making does work? This session will bring together three perspectives on how shared decision making can have a positive impact on patient safety.

4:15 PM – 6:15 PM

LEARNING & SIMULATION CENTER – Networking Reception, Simulations, Exhibits, Posters, Prize Drawings





BOOTH 417


BOOTH 711

Don’t miss the raffle drawings for prizes, at the NPSF booth in the Learning & Simulation Center:

Monday 6:00PM Tuesday 1:00PM and 6:00PM

Wednesday 1:00PM




WEDNESDAY, MAY 257:00 AM – 3:30 PMRegistration Open


8:00 AM – 9:15 AMKEYNOTE: Hot Topics in Patient Safety: Selected Papers

Advancing the Field in the Past YearTRAILBLAZERS BALLROOM, LEVEL 2Kaveh Shojania, MD, Director, Centre for Quality and Improvement and

Patient Safety, University of Toronto; Editor-in-Chief, BMJ Quality & Safety

The session will offer key elements of the top research papers of 2015 and address how the evidence-based patient safety interventions and effective strategies identified in these papers can be translated into practice.

9:45 AM – 10:45 AMCONCURRENT BREAKOUT SESSIONS

Track 1: Advancing Safety Science Implementation401: Practice Strategies to Reduce Catheter-Associated

Urinary Tract Infections (CAUTIs) Toward the Ideal Outcome “ZERO CAUTIs”HERBERGER 1, LEVEL 1Donna Armellino, DNP, RN, CIC, Vice President, Infection Prevention,

Northwell Health (previously North Shore-LIJ Health System)Catherine A. Galla, MSN, RN, CENP, Vice President, Nursing Initiatives,

Northwell Health (previously North Shore-LIJ Health System)Shelley Harris, RN, Chief Nursing Officer, Hospital Sisters Health System,

St. Elizabeth’s HospitalLeigh-Ann White, MSN, RN, CPHQ, Nurse Manager of Clinical Excellence

and Patient Safety Officer, Hospital Sisters Health System, St. Elizabeth’s Hospital

The session offers approaches in the use of indwelling urinary catheters at two health care organizations to minimize the risks for a CAUTI.

Track 2: Creating a Culture of Safety in the Workplace402: Improving Safety in Only 15 Minutes a Day!

HERBERGER 2, LEVEL 1Jackelyn Fleury, BS, Performance Improvement Coordinator and Policy

Management Analyst, Bassett Medical CenterRonette M. Wiley, RN, BSN, MHSA, CPPS, Vice President of Performance

Improvement, Bassett Medical Center

At Bassett Medical Center, emerging worries about the culture of safety became apparent in mid 2014. Patient safety event reporting was “stalled out,” and near miss reporting was declining. Leaders were not communicating in a meaningful way about safety concerns. Event investigation and resolution was significantly delayed. Finally, repeat issues were surfacing that were thought to have been “fixed” previously. Bassett Medical Center embarked on developing a safety huddle structure and system that employed a number of novel approaches in order to encourage and sustain engagement and accountability. As a result, the huddle quickly became an embedded and beloved part of the organization’s safety infrastructure. The resulting success has exceeded expectations.


403: Coaching as a Patient Safety Initiative in a Pediatric OrganizationGREENWAY, LEVEL 1Sharon Sables-Baus, PhD, RN, MPA, PCNS-BC, CPPS, Safety Nurse

Scientist, Children’s Hospital Colorado

Everyone has probably heard the phrase “children are not little adults,” but what does this mean in terms of pediatric patient safety? For one children’s

health care organization, it means including families and patients on safety project teams. The Family Centered Care Council Advisory Board, the Family Advisory Council, and the Youth Advisory Council (patients 13–18 years) provided input into developing the patient safety curriculum and implementation of a patient safety initiative “Target Zero: Eliminating Preventable Harm.” In this session attendees will learn how one particular program in this initiative used the Target Zero (TZ) Safety Coach to achieve zero preventable harm.


404: Implementation of the “Stop Sepsis” Program Leveraging Health IT: More Than Just an Intervention to Decrease Sepsis MortalityHERBERGER 4, LEVEL 1Allison R. Glasser, BSPT, MBA, Director of Operations Patient Safety,

Mount Sinai HospitalTuyet-Trinh Truong, MD, Hospitalist, Mount Sinai Hospital

This session will describe how a comprehensive sepsis program identifies septic and “other” decompensating patients (e.g. hypovolemia, GI bleeds, seizures, and heart failures). Discussion will highlight different tactics used to foster a culture of shared learning and to increase clinician accountability, to improve both the quality of care and outcomes for patients who are decompensating.

Track 5: Patient Safety Beyond the Walls of the Hospital405: A Translational Framework for Ambulatory Patient Safety

HERBERGER 5, LEVEL 1Jennifer Lenoci-Edwards, RN, MPH, CPPS, Director, Patient Safety Focus

Area, Institute for Healthcare ImprovementKathleen Walsh, MD, MSc, Director of Safety Research and Associate

Professor of Pediatrics, Cincinnati Children’s Hospital

The session will outline key findings from expert qualitative interviews and a multidisciplinary expert meeting with the goal of advancing patient safety understanding in the ambulatory setting. This session will propose a framework that outlines the key elements to developing a safe system that includes actionable recommendations and scenarios that map the domains to the frontline health care provider, middle management, and leadership.

Track 6: Sizzling in Scottsdale: Hot Topics in Patient Safety406: Free from Harm

HERBERGER 3, LEVEL 1Tejal Gandhi, MD, MPH CPPS, President and CEO, National Patient Safety

FoundationKaveh Shojania, MD, Director, Centre for Quality and Improvement and

Patient Safety, University of Toronto, Editor-in-Chief, BMJ Quality & Safety

Fifteen years after the Institute of Medicine brought public attention to the issue of medical errors and adverse events, patient safety concerns remain a serious public health issue that must be tackled with a more pervasive response. This session will provide a summary of the February 2015 expert panel discussions to assess the state of the patient safety field and set the stage for the next 15 years and the resultant Free from Harm report. Panel co-chair Dr. Kaveh Shojania, with Dr. Tejal Gandhi, President and CEO of NPSF, will discuss the recently released report and its recommendations for making patient and workplace safety a top priority.

11:00 AM – 12:00 PMCONCURRENT BREAKOUT SESSIONS

Track 1: Advancing Safety Science Implementation501: Improving Health Care Quality and Patient Safety

Through Peer-to-Peer Assessment: Demonstration Project in Two Academic Medical CenterHERBERGER 1, LEVEL 1


Elizabeth Mort, MD, Senior Vice President Quality and Safety, Massachusetts General Hospital

David Thompson, DNSc, MS, BSN, Health Services Researcher and Associate Professor, John Hopkins University

This session will present a demonstration project that was conducted to investigate making our institutions safer and tapping into our sense of professional obligation to review our performance. Building on the success of the methods used by the World Organization of Nuclear Operators, we designed, piloted, and evaluated the value of a similar protocol in health care.

Track 2: Creating a Culture of Safety in the Workplace502: A Data-Driven Approach to Optimizing Workplace Safety

HERBERGER 2, LEVEL 1Elena Canacari, RN, CNOR, Associate Chief Nurse, Perioperative Services,

Beth Israel Deaconess Medical CenterRoss Simon, BA, Senior Management Engineer, Beth Israel Deaconess

Medical Center

This session will discuss how to perform job safety observations and utilize tools to record hazards and recommendations to mitigate them.


503: Transition Care for Children with Complex NeedsGREENWAY, LEVEL 1Denise Micheletti-King, MS, RN, Chief Nursing Officer, Matheny Medical

and Educational CenterKenneth Robey, PhD, Director, Matheny Institute for Research in

Developmental Disabilities, Matheny Medical and Educational Center

Children with complex medical needs associated with cerebral palsy and related disorders utilize health care resources to a particularly high degree and at multiple levels of the continuum of care. Health care transitions occur frequently in this population, and the sources of risk in each of these transitions are many. This session will provide insight on the risk for children with complex developmental disabilities in health care transitions, along with strategies implemented to manage risk, including use of a Transition Medical Record and involvement of a transition nurse throughout the care episode.


504: Improving Infusion Pump Safety through Usability TestingHERBERGER 4, LEVEL 1Michele Campbell, RN, MS, CPHQ, FABC, Vice President, Patient Safety

and Accreditation, Christiana Care Health System Kristen Miller, MD, Associate Director, Human Factors, Value Institute,

Christiana Care Health System

This session will provide evidence-based information on the benefits of conducting usability testing for medical devices at a local level, with the intent to improve the implementation and use of the device-user interface such that errors that occur during use of the device are either eliminated or reduced. The session will provide updated information on usability testing as a very useful human factors method that provides direct information on the interaction between people and their work environment or tools. A discussion on simulated use will be provided to capture the complexity and preserve the context of the work environment within which health information technology is implemented.

Track 5: Patient Safety Beyond the Walls of the Hospital505: Engaging Patients and Staff to Reduce UTI Diagnosis

ErrorsHERBERGER 5, LEVEL 1Paula Griswold, MS, Executive Director, Massachusetts Coalition for the

Prevention of Medical Errors

Through didactic presentations, alternated with small group discussions of case studies and tools, this session will present the lessons learned from an improvement collaborative with more than 30 long-term care facility teams, who reduced inappropriate testing and diagnosis of urinary tract infections (UTI).

Track 6: Sizzling in Scottsdale: Hot Topics in Patient Safety506: Time to Get It Right: How Mass Confusion Surrounding

Living Wills and POLST Forms May Lead to Patient Safety Risks in Your Emergency Room and Hospital, and What You Can Do About ItHERBERGER 3, LEVEL 1Ferdinando L. Mirarchi, DO, FAAEM, FACEP, Medical Director, Department

of Emergency Medicine, and Chairman, Hamot Physician Network Governance Council, University of Pittsburgh Medical Center; CEO and Chief Medical Officer, Institute of HealthCare Directives, University of Pittsburgh Medical Center

Steven Montague, MSc, Executive Vice President, LifeWings Partners, LLC

This session will provide current information regarding the potential risks to patients as a result of misunderstandings and lack of attention paid to advance directives. Advance directives, DNR (Do Not Resuscitate) orders, and POLST (Physician Orders for Life Sustaining Treatment) documents do have an impact on patient care and safety when providers do not understand the scope, application, or content of such documents. This session will provide an update on the newly disclosed and discovered risk to patient safety that requires immediate action surrounding the way health care professionals react to such documents.

12:00 PM – 1:30 PM

LEARNING & SIMULATION CENTER – Lunch, Simulations, Exhibits, Posters, Prize Drawings


SIMULATIONS12:00 PM – 12:30 PM Simulation 1: The Heart, It Matters: A

Cardiac Event BOOTH 211


BOOTH 417


BOOTH 711

1:45 PM – 3:00 PMKEYNOTE: Thriving in Health Care: Your Blueprint for

Resilience and Burnout PreventionTRAILBLAZERS BALLROOM, LEVEL 2Paula Davis-Laack, JD, MAPP, Internationally Published Writer, Recovering

Lawyer, and Burnout Resilience Expert

Burnout has been called the occupational hazard of the 21st century. Recent studies show that almost 70% of people show up to work disengaged on some level. In health care, the latest research shows that more than 50% of health care professionals are either burned out or on a path to burnout. This costs health care organizations millions of dollars each year in lost productivity, patient safety issues, increased malpractice risk, absenteeism, presenteeism, and turnover. This session will provide a first-hand case study that will enhance your knowledge on the warning signs of burnout and how to apply proactive strategies to prevent your own burnout.

Don’t forget to turn in your CE/CME paperwork at the Congress registration desk


18th Annual NPSF Patient Safety CongressMay 23–25, 2016 | Scottsdale, Arizona


Kirkland

NellieCashman’sMondayClub Cafe

Deseo

Terrace

Nob

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GREENWAYBreakouts Track 3

Visi

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Hal

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Terr

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Billi

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Waltz & WeiserWhiskey Bar andCantina

Terrace

North Foyer

Northern Sky Terrace

RainmakersBallroom

East

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HERBERGER 2Breakouts Track 2

MuddleBar

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Terr

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WESTIN KIERLANDLEVEL 2

LOBBY LEVEL

Pathfinders

Tang

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Mapmakers

Explorers TerraceEx

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KierlandMining Co.

WhippleParke Sitgreaves

Tribal

FedExBusinessCenter

Front Desk Concierge

MainEntry

Desert Dwellers Circle

TheRimBar

Lobby LoungeScotchLibrary

Co�eeFlats &

Snowbowls

Toon

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6Tr

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Hal

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Stargazers Terrace

Merriam Lowell

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Trailblazers Terrace

TRAILBLAZERS BALLROOMKeynote Sessions

Trailblazers South

HALL OF STATE

NPSF Congress Registration

KIERLAND GRAND BALLROOM

NPSF Learning & Simulation Center

Culturekeepers Hall South

ENTRANCE

WESTIN KIERLANDLEVEL 1

LOWER LEVEL





Immersion Workshops, Monday May 23CPPS Review Course HERBERGER 4Leadership Day HERBERGER 5Communication and Resolution Programs GREENWAYPatient Safety Science HERBERGER 2


Join us next year for the 19th Annual NPSF PATIENT SAFETY CONGRESS Renaissance Orlando at SeaWorld | May 17–19, 2017

schedule - cdn.ymaws.com · accountability and improvement and npsf. despite our best efforts as...

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