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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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