Download 25 years of “ah-ha” moments. experience the collective impact

The 25th Annual IHI National Forum
on Quality Improvement in Health Care
December 8-11, 2013 Orlando, FL
•
25 years of “ah-ha” moments.
experience the collective impact.
National Forum
T R Y I T F R E E AT W W W. D E B M E D. C O M
THINGS CHANGE. FOR GOOD REASON.
I F Y O U ’ R E S T I L L U S I N G D I R E C T O B S E R VAT I O N T O C A L C U L AT E
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Antiquated Methods. Unreliable Data.
Lead the Change
Dear Colleagues,
Wow—25 National Forums. A quarter century of improving care for patients, together. It’s
almost hard to believe. So much has changed! I remember when cataract surgery meant a
seven-day hospital stay, with the patient immobilized by sandbags and restricted to a liquid
diet. Now it’s a simple outpatient procedure, often with the family watching in the room.
We’ve gone from improving individual practices and units to improving whole systems; from
care for individuals to care for populations; and, most importantly, from caring for patients
to caring with patients. We are now co-producers of care—active partners working with
patients to improve care and health.
I’m confident that, thanks to the extraordinary effort, dedication, and passion from all of you
and your colleagues, health care today is better and safer. And perhaps for the first time,
there is universal commitment to reducing the costs of care. IHI’s Triple Aim has provided
a holistic framework for improvement to professionals and organizations around the world.
We’re tearing down silos and bridging chasms.
We have come a long way, and achieved so much together. But I know you’ll agree that
we have much more work to do. For 25 years, the National Forum has been the place to
convene and learn about what works in health care improvement. It’s been the place to
find the latest innovations and connect with the most inspiring leaders. Twenty-five National
Forums have taught us what works, and now we need to spread what works everywhere,
so all patients will benefit. We can do this, together. That’s what this National Forum is
about—collective impact.
We’re seeing how collective impact happens on a small scale. The revolution of carefully
coordinated care is improving patients’ experiences and outcomes everywhere.
Multidisciplinary teams are streamlining processes, removing barriers to effective
communication and cooperation, and creating new models of care every day. Now
we need to go bigger. IHI’s work on the Triple Aim in communities; our work to bring
employers, providers, and health plans together to improve health and reduce costs;
our work to ensure that everyone has “the conversation” about end-of-life care—these
are examples of the power and promise of collective impact.
Almost 10 years after we launched the 100,000 Lives Campaign, I’m still asked to speak
about it. People everywhere are still keenly interested in how to bring disparate groups of
people together around a common goal, and then achieve that goal. IHI was only about
50 people back then. I’m sure some thought we were crazy to start a national patient
safety campaign. But there’s a famous quote that inspired us then and sustains us now
—it’s printed on a wall outside my office—“Never doubt that a small group of thoughtful,
committed citizens can change the world. Indeed, it is the only thing that ever has.” At
this National Forum, we want to hear from you as we plan our next big initiative: A global
collaborative to transform care and health worldwide. It might seem strange to think of the
thousands gathered here this week as a “small group,” but you represent tens of millions
of health professionals around the world. You are the small group of thoughtful, committed
citizens that will have a collective impact, improving the health and lives of patients and
families everywhere. Enjoy the National Forum.
Sincerely,
table of
Contents
Agenda-at-a-Glance......................................... 2
Keynotes............................................................ 6
Special Interest Keynotes.................................. 7
Sunday, December 8
Learning Labs................................................... 8
Monday, December 9
Forum Excursions............................................ 13
Virtual Site Visits............................................ 14
Scientific Symposium...................................... 15
Minicourses..................................................... 16
Welcome Reception......................................... 20
Student and Faculty Reception ...................... 20
Tuesday, December 10
25th National Forum Celebration...................... 5
Keynote One: Maureen Bisognano................... 21
Workshops A and B ......................................... 22
Keynote Two: Eric Weihenmayer....................... 24
Workshop C .................................................... 26
Storyboard Reception...................................... 48
Wednesday, December 11
Special Interest Breakfasts .............................32
Keynote Three:
Dr. Nancy Snyderman & Lindsay Beck ...........33
Workshops D and E .........................................33
Keynote Four: Dr. Donald Berwick ....................36
IHI Onsite App Instructions .............................. 4
Networking Events............................................ 4
Post-Conference Recordings............................. 5
Shuttle Map.................................................... 38
Conference Map ............................................. 40
Conference Information ................................. 43
Exhibit Hall Floor Plan .................................... 46
Continuing Education .................................... 47
Storyboards .................................................... 48
Index by Presenter .......................................... .58
Exhibitors ....................................................... 60
Maureen Bisognano
President and CEO, Institute for Healthcare Improvement
Welcome! Tweet using #IHI25Forum
1
Forum Agenda at a glance
7:00 AM
Pre-Conference
8:00 AM
9:00 AM
10:00 AM
11:00 AM
12:00 PM
7:00 AM – 5:30 PM Registration Open
11:00 AM –12:00 PM
National Forum
Orientation
Crystal Ballroom,
Salon G
Sunday
DECEMBER 8
Pre-Conference
Monday
6:30 AM – 5:30 PM Registration Open
7:00 AM – 8:00 AM
National Forum
Orientation
and Continental
Breakfast*
8:30 AM – 4:00 PM Minicourses (lunch provided)
Crystal Ballroom,
Salon G
8:30 AM – 5:00 PM Forum Excursions (lunch provided) Departing from the G Gaylord Palms DECEMBER 9
8:30 AM – 4:30 PM Virtual Site Visits (lunch provided)
8:30 AM – 5:00 PM Scientific Symposium (lunch provided) Sun Ballroom A
* Breakfast provided for Minicourse, Virtual Site Visit, Forum Excursion, and Scientific Symposium attendees
Conference DAY 1
Tuesday
DECEMBER 10
6:30 AM – 5:30 PM Registration Open
7:00 AM – 8:00 AM
National Forum
Orientation
and Continental
Breakfast
Crystal Ballroom,
Salon G
8:00 AM – 9:00 AM
Keynote One:
Maureen
Bisognano
Cypress
Ballroom 3
9:30 AM – 2:45 PM CEO and Leadership Summit Grand Ballroom, Salon 8
9:30 AM – 10:45 AM
Workshop A
10:30 AM – 1:30 PM Exhibit Hall Open Palms Ballroom
11:15 AM – 12:30 PM
Workshop B
(repeat of Workshop A)
Conference Day 2
6:30 AM – 1:30 PM Registration Open
7:00 AM – 8:00 AM
Continental
Breakfast
Wednesday
DECEMBER 11
2
7:00 AM – 7:45 AM
Special
Interest
Breakfasts
8:00 AM – 9:00 AM
Keynote Three:
Dr. Nancy
Snyderman
and Lindsay Beck
10:30 AM – 1:30 PM Exhibit Hall Open Palms Ballroom
9:30 AM – 10:45 AM
Workshop D
Cypress
Ballroom 3
25th Annual National Forum on Quality Improvement in Health Care
11:15 AM – 12:30 PM
Workshop E
(repeat of Workshop D)
1:00 PM
2:00 PM
3:00 PM
4:00 PM
5:00 PM
6:00 PM
7:00 PM
5:00 PM – 7:00 PM
International Attendees Meeting
1:00 PM – 4:30 PM
Learning Labs
Crystal Ballroom, Salon D
4:30 PM – 7:30 PM 6th Annual Open School Chapter Congress
Sponsored by Kaiser Permanente
7:00 PM – 9:00 PM
Faculty and Student
Reception
Resort and Convention Center
3:30 PM – 6:30 PM Welcome Reception Palms Ballroom
G Gaylord Palms,
Emerald Bay Plaza
3:15 PM – 4:15 PM
Keynote Two:
Eric
Weihenmayer
12:30 PM – 1:30 PM
Lunch
1:30 PM – 2:45 PM
Workshop C
Cypress
Ballroom 3
4:15 PM – 6:30 PM Exhibit Hall Open
Palms Ballroom
4:30 PM – 6:30 PM
Storyboard Reception
Palms Ballroom
6:30 PM – 10:00 PM
25th National Forum Celebration
Pool Pavilion
STAY CONNECTED
12:30 PM – 1:30 PM 1:30 PM – 2:30 PM
Lunch
Keynote Four:
Dr. Donald
Berwick
Stay connected with IHI and your fellow National Forum attendees!
Use the hashtag #IHI25Forum when tweeting.
Be sure to follow IHI on Twitter, Facebook, LinkedIn, and our IHI blogs.
Cypress
Ballroom 3
Welcome! Tweet using #IHI25Forum
3
Forum App:
IHI ONSITE
IHI Forum App for All
Smartphones: IHI Onsite
The IHI Forum app (IHI Onsite) serves
as your all-in-one event guide by putting
everything you need to know right onto
your mobile device.
Networking
Events
The IHI National Forum provides many networking opportunities
including during lunches, breaks, and receptions, while doing yoga,
and on Twitter using #IHI25Forum.
The IHI Forum app will enable you to:
Don’t miss these networking events:
• Browse all of the National Forum
session descriptions (including
Learning Labs, Minicourses,
General Conference workshops, etc)
Welcome Reception
• Take notes in sessions that will be
saved to your IHI profile
• Browse full faculty biographies
• See Twitter updates using the
conference hash tag #IHI25Forum
• Locate events and rooms using an
interactive map of the Marriott space
• Check out exhibitor descriptions
and booth locations
Monday, December 9
3:30 PM – 6:30 PM
Exhibit Hall - Palms Ballroom
Complimentary Yoga
Tuesday, December 10
6:00 AM – 7:00 AM
Key Largo
Social Media 101 Lunch n’ Learn
Tuesday, December 10
12:40 PM – 1:20 PM
Grand Ballroom, Salon 7
The IHI Forum app is available for free
in the App Store and Android Market.
Search either store for “IHI Onsite”
and download yours today.
Once you have downloaded the
IHI Onsite app:
Tuesday, December 10
12:40 PM – 1:20 PM
Crystal Ballroom, Salon H
Storyboard Reception
• Ensure you are connected
to the internet
Tuesday, December 10
4:30 PM – 6:30 PM
• Launch the app
Exhibit Hall - Palms Ballroom
• Enter your last name as
your username
NEW! 25th National Forum Celebration
• Enter your order ID for this event
as your password (available under
the bar code on your name badge
— the numbers after and not
including OID)
Pavilion Pool
• Click “Verify”
For help with the IHI app, please ask
any IHI Blue Shirt.
4
Be the Change: Three Things Needed to Achieve Health Equity
Tuesday, December 10
6:30 PM – 10:00 PM
Join us to celebrate 25 years of health care
improvement and toast the good work yet to come.
Special Interest Breakfasts
Wednesday, December 11
7:00 AM – 7:45 AM
See page 32 for details and locations.
25th Annual National Forum on Quality Improvement in Health Care
25 National Forum
Celebration
th
National Forum
Tuesday, December 10
6:30 PM – 10:00 PM
Pool Pavilion
Join us by the Marriott pool to celebrate 25 years
of health care improvement. We’ll provide food, drinks,
and entertainment (including an a capella group and
dueling pianos!) This event is free of charge.
Post-National Forum Recordings
If you attended the National Forum General Conference in person, in January you will receive:
•
FREE audio synced with PowerPoint slides
for every General Conference workshop
•
FREE videos of keynote and special interest
keynote presentations
Registered attendees will receive an email from IHI in January with
instructions on how to access the recordings and videos.
5
KEYNOTES
Keynote One: Maureen Bisognano
Tuesday, December 10 • 8:00 AM – 9:00 AM
Cypress Ballroom 3
Maureen Bisognano, President and CEO, Institute for
Healthcare Improvement (IHI), is a prominent authority
on improving health care systems, whose expertise has
been recognized by her elected membership to the
Institute of Medicine and by her appointment to
The Commonwealth Fund’s Commission on a High
Performance Health System, among other distinctions.
Ms. Bisognano advises health care leaders around
the world, is a frequent speaker at major health care
conferences on quality improvement, and is a tireless
advocate for change. She is also an Instructor of Medicine at Harvard Medical
School and a Research Associate in the Brigham and Women’s Hospital Division
of Social Medicine and Health Inequalities. Prior to joining IHI, she served as
CEO of the Massachusetts Respiratory Hospital and Senior Vice President of
the Juran Institute.
Keynote Two: Erik Weihenmayer
Tuesday, December 10 • 3:15 PM – 4:15 PM
Cypress Ballroom 3
Erik Weihenmayer is one of the most inspiring, engaging,
and sought after speakers in the world. Despite losing
his vision at age 13, Erik has become an accomplished
mountain climber, paraglider, skier, and kayaker who
never let blindness interfere with his passion for an
exhilarating and fulfilling life. Erik’s powerful message
speaks to harnessing the power of adversity and using it
as fuel for greatness. He sees every new challenge as an
opportunity to problem solve, strategize, and create a new
way forward. Citing stories from his thrilling journeys, Erik’s presentations embrace
a passion for discovery and innovation. He believes in being a pioneer, in making
the impossible possible, and opening up a new world of opportunity for yourself,
your organization, and your team. His accomplishments show that one does not
have to have perfect eyesight to have extraordinary vision. In May 2001, Erik
Weihenmayer became the only blind person in history to reach the summit of
Mount Everest, and in 2008, he completed his quest to climb the Seven
Summits—the highest mountain on each continent. Additionally, he has
ascended dozens of major peaks, rock walls, and ice climbs around the
planet. These include the first blind ascent of the 2,900-foot Nose of El Capitan
in Yosemite, a difficult alpine climb of the spectacular 19,511-foot Alpamayo in
Peru, and an ascent of a rarely climbed 3,000 foot frozen waterfall in Nepal.
Keynote Three: P
Nancy Snyderman, MD, and Lindsay Nohr Beck
Wednesday, December 11 • 8:00 AM – 9:00 AM
Cypress Ballroom 3
Nancy Snyderman, MD, is Chief Medical Editor of NBC
News. Dr. Nancy Snyderman joined NBC News as the
Chief Medical Editor in 2006. Her reports appear on
Today, NBC Nightly News with Brian Williams, Dateline
NBC, and MSNBC. She has reported on a wide range of
medical topics and has travelled the world extensively,
reporting from many of the world’s most troubled areas.
Dr. Snyderman is a fully trained pediatric otolaryngologist
and currently remains on the staff of the Department of
Otolaryngology-Head and Neck Surgery at the University of Pennsylvania. Dr.
Snyderman’s medical work has been widely published in peer review journals,
and she is the recipient of numerous research grants as well as awards for her
6
broadcasting work. She is the author of Medical Myths That Can Kill You,
among other publications, and she writes a monthly column for Good
Housekeeping magazine.
Lindsay Nohr Beck is a respected patient advocate
most well known for her work in oncology. She currently
consults for several non-profit and for-profit companies
based on her resounding success as the visionary leader
of Fertile Hope. Most recently, Lindsay served as a Cancer
& Fertility Advisor for the LIVESTRONG Foundation where
she led a groundbreaking initiative with major insurance
providers to reform health care benefits for cancer
patients. Lindsay joined LIVESTRONG after the
organization acquired Fertile Hope, the company that she founded to address
the profound reproductive needs of cancer patients and survivors—a need
she discovered after her own experience with recurrent tongue cancer in her
early 20s. Under Lindsay’s leadership, Fertile Hope strategically integrated two
disparate medical specialties by changing the standard of care and catalyzing
the establishment of a new medical discipline now called “oncofertility.” She
has co-authored several papers on the subject, most notably ASCO’s Fertility
Preservation Guideline, presented extensively around the world, and appeared
in numerous media outlets, including the TODAY show, Wall Street Journal,
New York Times, and SELF magazine. Additionally, she is the co-author of
100 Questions & Answers About Cancer and Fertility.
Keynote Four: Donald M. Berwick, MD, MPP
Wednesday, December 11 • 1:30 PM – 2:30 PM
Cypress Ballroom 3
Donald Berwick, MD, MPP, is President Emeritus and
Senior Fellow at the Institute for Healthcare Improvement
(IHI), an organization that Dr. Berwick co-founded and
led as President and CEO for 18 years. He is one of the
nation’s leading authorities on health care quality
and improvement. In July, 2010, President Obama
appointed Dr. Berwick to the position of Administrator of
the Centers for Medicare and Medicaid Services (CMS),
which he held until December, 2011. A pediatrician by
background, Dr. Berwick has served as Clinical Professor of Pediatrics and
Health Care Policy at the Harvard Medical School, Professor of Health Policy and
Management at the Harvard School of Public Health, and as a member of the
staffs of Boston’s Children’s Hospital Medical Center, Massachusetts General
Hospital, and the Brigham and Women’s Hospital. He has also served as vice
chair of the U.S. Preventive Services Task Force, the first “Independent Member”
of the Board of Trustees of the American Hospital Association, and chair of the
National Advisory Council of the Agency for Healthcare Research and Quality.
An elected member of the Institute of Medicine (IOM), Dr. Berwick served two
terms on the IOM’s governing Council and was a member of the IOM’s Global
Health Board. He served on President Clinton’s Advisory Commission on
Consumer Protection and Quality in the Healthcare Industry. He is a recipient of
numerous awards, including the 1999 Joint Commission’s Ernest Amory Codman
Award, the 2002 American Hospital Association’s Award of Honor, the 2006
John M. Eisenberg and Quality Award for Individual Achievement from the
National Quality Forum and the Joint Commission on Accreditation of Healthcare
Organizations, the 2007 William B. Graham Prize for Health Services Research,
the 2007 Heinz Award for Public Policy from the Heinz Family Foundation, the
2012 Gustav O. Lienhard Award from the IOM, and the 2013 Nathan Davis
Award from the American Medical Association. In 2005, he was appointed
“Honorary Knight Commander of the British Empire” by the Queen of England,
the highest honor awarded by the UK to non-British subjects, in recognition of
his work with the British National Health Service. Dr. Berwick is the author or
co-author of over 160 scientific articles and four books. He also serves now as
Lecturer in the Department of Health Care Policy at Harvard Medical School,
and as a Senior Fellow at the Center for American Progress.
25th Annual National Forum on Quality Improvement in Health Care
Special Interest
workshop
Tracks
keynotes
A1: Removing Waste From Health Care: Lessons from
Choosing Wisely and the Right Care Alliance
Tuesday, December 10 • 9:30 AM - 10:45 AM
Daniel Wolfson, Executive Vice President & COO, ABIM Foundation
Shannon Brownlee, Senior Fellow, Lown Institute
Vikas Saini, President and CEO, Lown Institute
Seventy-five workshops are offered during
the General Conference (December 10
and 11). The sessions are organized into
content areas—or “tracks”—that follow
IHI’s five focus areas. Participants can
enroll in sessions individually or follow
one of these strategic tracks:
Tracks
B1: Global Lessons in Improvement from Around the World
Tuesday, December 10 • 11:15 AM - 12:30 PM
Nigel Crisp, Former Permanent Secretary in Health, United Kingdom and Former
Chief Executive, National Health Service England (Moderating a panel including):
Göran Henriks, Chief Executive of Learning and Innovation, The County Council
of Jönköping, Sweden
Wim Schellekens, MD, Strategic Advisor, The Hague Area, The Netherlands
Jason Leitch, Clinical Director, Quality Unit, Scottish Government Health Department, Scotland
Haidee Davis, General Manager, Ko Awatea, Counties Manukau District Health Board, New Zealand
Sodzi Sodzi-Tettey, MD, Executive Director, Department of Health, National Catholic Secretariat, Ghana
Mike Richmond, Chief of Clinical Affairs, Hamad Medical Corporation, Qatar
• Quality, Cost, and Value
• Improvement Capability
• Triple Aim for Populations
• Person- and Family-Centered Care
• Patient Safety
Session Levels at a Glance
The General Conference offers workshops
for various levels of learning. Sessions
are sorted by experience level throughout
this guide.
C1: Fully Transparent Medical Records: Prospects and Problems
Tuesday, December 10 • 1:30 PM - 2:45 PM
Tom Delbanco, MD, Professor of General Medicine and Primary Care,
Harvard Medical School and Beth Israel Deaconess Medical Center
and Co-Director, OpenNotes
F Fundamentals Program
This series of sessions offers helpful
ideas and tools for newcomers to the
world of quality improvement.
Jan Walker, RN, Principal Associate in Medicine, Harvard Medical School
and Beth Israel Deaconess Medical Center and Co-Director, OpenNotes
M Masters Program
D1: The Role of Leaders in Building a Culture of Continuous Improvement
Wednesday, December 11 • 9:30 AM - 10:45 AM
For the advanced learner, this series
of sessions provides cutting-edge
improvement thinking from health
care and other industries.
Shahab Saeed, Vice President & COO, Questar Energy Services
S Student Program
E1: Environmental Sustainability and the IHI Triple Aim
Wednesday, December 11 • 11:15 AM - 12:30 PM
Donald Berwick, MD, MPP, President Emeritus and Senior Fellow,
IHI (Moderating a panel including):
Blair Sadler, Senior Fellow, IHI
Gary Cohen, Executive Director, Health Care Without Harm
Selected across a wide spectrum of
topics and disciplines, these sessions will
accelerate the capacity for improvement
of health professions students who are
new to quality improvement or new to
the National Forum.
P Patient Presenters
The sessions designated with a “P” will
have a patient presenting as faculty.
Robin Guenther, CEO, Perkins+Will Consulting Practice
Jeffrey Thompson, MD, CEO, Gundersen Health System
Welcome! Tweet your Forum thoughts using #IHI25Forum
7
PRE-CONFERENCE
Sunday
DECEMBER 8
(Plan, Do, Study, Act) by integrating them into
their project planning and process design
• Initiate a plan to build an integrated quality
improvement strategy
Scoville, R., PhD, Improvement Advisor and
Consultant, IHI; Zak, H., President and COO,
ThedaCare Center for Healthcare Value;
Norouzzadeh, S., Industrial Engineer,
North Shore – LIJ
L2: Building Capacity and Capability:
The Really Big Challenge
Grand Ballroom, Salon 7
Crystal Ballroom, Salon G
Many organizations claim that their efforts are well
positioned to achieve the desired results. Many
organizations, however, only give lip service to
the role and position of QI within the organization.
Are you REALLY serious about building capacity
for QI? This session will define the key components of a capacity-building strategy, identify the
milestones in the capacity-building journey, and
describe how to assess your organization’s
capacity for sustained change.
If you are new to the National Forum, we
suggest that you attend one of the National
Forum orientation sessions to help you navigate
through the program and devise a personal
learning plan. Participation in the National
Forum orientation is free, and registration is
not required.
After this session, participants will be able to:
• Define the key components of a
capacity-building strategy
• Identify key milestones in the
capacity-building journey
• Assess their organization’s capacity for
sustained change
National Forum
Orientation
11:00 AM – 12:00 PM
Learning Labs
1:00 PM – 4:30 PM
Learning Labs offer specific “how-to”
improvement information. These half-day
sessions allow full engagement, discussion,
and ample time for Q&A.
L1: Building an Integrated Approach
to Lean, Six Sigma, and the Model
for Improvement
Crystal Ballroom, Salon D
What approach to quality improvement does your
organization follow? Lean, Six Sigma, The Model
for Improvement (M4I)? All approaches have
value, but many organizations lack what Edwards
Deming called “constancy of purpose” and end up
confused about which methods are best and how
to apply them in specific contexts. This workshop
will help participants clarify the similarities and
differences between these three approaches,
provide a framework for organizing their overall
quality improvement strategy, and offer hands-on
experience with key Lean and M4I tools.
After this session, participants will be able to:
• Describe the similarities and differences
between Lean, Six Sigma, and M4I
approaches to quality improvement
• Select and apply important Lean and M4I tools,
such as Value Stream Mapping, A3 design,
Quality as a Business Strategy, and PDSA
8
L4: How Much Is Enough?
Sampling for Improvement M
Crystal Ballroom, Salon K-M
Sampling methods for improvement differ from
those associated with research and judgment
measures, and confusion on this point can lead
to sampling waste, inefficiencies, and delayed
learning. This session will present practical criteria
to determine appropriate sample sizes for
quality improvement work, as well as the resource
burden of sampling. Specific topics include
guidelines for scaling PDSA cycles and
determining appropriate sample sizes for
run charts and Shewhart control charts.
After this session, participants will be able to:
• Describe the principles for sampling
for improvement
• Estimate the resource burden of sampling
• Select appropriate scale for PDSA cycles
Murray, S., Improvement Advisor, CT Concepts;
Provost, L., Statistician, Associates in Process
Improvement; Perla, R., Director, Analytics,
University of Massachusetts Memorial Medical Center
Luther, K., RN, Vice President, IHI; Kotagal, U.,
Senior Vice President, Quality and Transformation,
and Director, Health Policy and Clinical Effectiveness, Cincinnati Children’s Hospital Medical Center;
Schilling, L., RN, National Vice President, Healthcare
Performance Improvement, Kaiser Permanente
Improvement Capability
L3: Health Care 3.0—
The Nuka System of Care
Increasingly, state, regional, or national indicators
are used for accountability assessments of the
quality and safety of health care providers, usually
aggregated by quarter or year and most often
lagged by a year or more. These indicators are not
typically used for improvement. This session
will not only clarify the different approaches to
measurement but also show how to fully integrate
aggregated outcome indicators into an organization’s improvement journey. Rather than ignoring
or challenging aggregated national indicators or
rationalizing their position in a rank ordering of
providers, leaders should be using these data
to develop a more integrated approach to
measurement. Both statistical and graphical
data integration will be demonstrated in this
session. Participants will also be challenged to
assess their own measurement systems and
articulate their reasons for measuring.
Sawgrass
Quality, Cost, and Value
Tierney, S., MD, Chief Medical Informatics
Officer and Medical Director, Clinic Quality
Improvement, Southcentral Foundation;
Eby, D., MD, Vice President of Medical Services,
Southcentral Foundation
Southcentral Foundation, awarded the Malcolm
Baldrige National Quality Award in 2011, has
been a National Center for Quality Assurance
(NCQA) patient-centered medical home
(PCMH), Level 3 (highest level), since 2010.
The standards of the PCMH are just the starting
point for transforming a health care system. This
session will review approaches that go beyond
the PCMH starting point to create and sustain
relationships, including approaches for the
recruitment, retention, and training of workforce;
and for information management from data
systems to support the new approach.
After this session, participants will be able to:
• Review an entire health care system’s
transformational journey from
physician-centered to patient-centered
to customer-owned
• Detail the ways in which a health care system
that has been redesigned and rebuilt from the
perspective and ownership of the community
results in better outcomes than a faster and
leaner version of the current medical system
• Describe approaches for moving beyond
PCMH to Health Care 3.0, including workforce
and information management from data
systems and sustaining relationships
L5: Are National Indicators Useful
for Improvement Work?
Grand Ballroom, Salon 8
After this session, participants will be able to:
• Explain the differences and similarities
between measurement for improvement,
judgement, and research
• Describe ways to analyze data for improvement
• Assess their personal approach and their
organization’s approach to measurement
Lloyd, R., PhD, Executive Director, Performance
Improvement, IHI; Henriks, G., Chief Executive
of Learning and Innovation, County Council
of Jönköping
25th Annual National Forum on Quality Improvement in Health Care
L6: Design Your Way to Better Service
Crystal Ballroom, Salon J
Design methods bring new insights and
understanding about how you are actually
providing services… and show you that all
is not what you think. As they learn, share,
laugh, and generally have fun, participants
in this highly interactive workshop will gain
hands-on experience in using effective service
design approaches to transform the services
they provide.
After this session, participants will be able to:
• Articulate what they don’t know about the
services they provide
• Experiment with new approaches to providing
better service in their own organization
Maher, L., PhD, Director for Innovation, Ko Awatea;
McCarthy, C., Director, Innovation Learning Network,
Kaiser Permanente
L7: Designing for Flow: Who’s
Caring for Mary?
New York/New Orleans
Lack of flow within a hospital often stems from
poorly designed systems that lack sufficient
resources. Such systems are also associated
with increased harm to patients. Designing for
flow has safety benefits not only for patients
but also for organizations. This Learning Lab
will describe the links between flow and harm,
providing methods for identifying flow issues and
detailing concepts that can be used to improve
flow and consequent safety.
After this session, participants will be able to:
• Identify system defects and opportunities
to improve flow within their organization
• Develop strategies for understanding and
preempting flow issues
• Implement recognized strategies for
system redesign
Boulton, J., MB ChB, Consultant Rheumatologist
and Clinical Lead for Quality Improvement, Sheffield
Teaching Hospital; Mackenzie, S., Medical Director
for Quality Improvement and Safety, NHS Lothian
L8: Disaster Management in Health
Care: Principles and Practices of
Emergency Preparedness
Grand Ballroom, Salon 9-10
Emergency preparedness involves more
than just having a plan. To be truly prepared,
a comprehensive approach is required that
ensures the safety of patients, employees,
and the surrounding community while
maintaining continuity of operations. This
session will detail lessons learned by the
North Shore-LIJ Health System during various
types of incidents (terrorism, infectious disease
outbreaks, and weather-related emergencies)
and how these lessons were integrated into a
comprehensive emergency management program
After this session, participants will be able to:
• Prepare a comprehensive emergency
management program
• Describe the steps necessary to ensure
the safety of patients, employees, and
the community during an incident
• Discuss vital components of a business
continuity plan
Solazzo, M., Executive Vice President and Chief
Operating Officer, North Shore-LIJ; Jarrett, M., MD,
Senior Vice President/Associate CMO and Chief
Quality Officer, North Shore-LIJ; Romagnoli, J.,
Vice President, Protective Services, North Shore-LIJ;
Mahoney, M., NP, Director, Emergency Planning
and Preparedness, North Shore-LIJ
L9: Enhance Safety and Reduce
Cost by Improving Flow
Crystal Ballroom, Salon N
The need to develop new ways to deliver health
care has become more apparent with funding
constraints and the failure of safety systems.
This session will demonstrate how to deliver
safe and effective care in a cost-effective way.
Participants will learn why the application of
operations management theory is the key to an
affordable and safe health service. The principles
of the management of variability and queuing
theory will be illustrated by case studies and
participatory work.
After this session, participants will be able to:
• Explain the relationship between flow,
safety, and cost
• Implement the principles of managing
operations
• Describe the key challenges in redesigning
the flow of patients to improve safety
Litvak, E., PhD, President and CEO, Institute for
Healthcare Optimization; Lachman, P., MD, Associate
Medical Director and Consultant in Service Redesign
and Transformation, Great Ormond Street Hospital
for Children NHS Trust; Leitch, J., Clinical Director,
Quality Unit, Scottish Government Health Department
L10: How to Publish Your
Improvement Work M
Vinoy
This session will advance participants’ writing
skills with the goal of reporting on their health
care improvement efforts for scholarly publication. Participants will bring their own improvement
work—at any stage of development—for use
in hands-on writing exercises. Faculty will
employ a new draft version of the SQUIRE
publication guidelines for reporting health
care improvements to help participants
prepare their work for publication. This
session will also provide timely updates
on health care improvement science and
obtaining appropriate ethics reviews.
After this session, participants will be able to:
• Use writing techniques that are applicable
to scholarly publication of their health care
improvement efforts
• Apply the evolving SQUIRE publication
guidelines to achieve greater success
in publication
Stevens, D., MD, Editor Emeritus, BMJ Quality & Safety,
The Dartmouth Institute for Health Policy and Clinical
Practice; Batalden, P., MD, Professor, The Dartmouth
Institute for Health Policy and Clinical Practice;
Davidoff, F., MD, Executive Editor, IHI; Davies, L., MD,
Assistant Professor of Surgery, Dartmouth Medical
School; Ogrinc, G., MD, Associate Professor,
Community and Family Medicine, White River
Junction VA Medical Center
L11: How to Transform Your
Practice into a Medical Home F
Crystal Ballroom, Salon G
The patient-centered medical home (PCMH)
has rapidly gained momentum as a strategy for
delivering high-quality, affordable health care.
By emphasizing a comprehensive, collaborative
working relationship between clinicians, patients,
and families, the model creates a team-based,
data-driven infrastructure in which care is
coordinated, community resources are integrated,
and patients are supported as decision-makers.
This Learning Lab will focus on building internal
capacity to lead change efforts to help transform
your practice into a medical home.
After this session, participants will be able to:
• Identify the elements and benefits of the PCMH
• Determine the barriers and challenges that
must be overcome to implement this model
in their own practice
• Develop a plan for designating and training a
local leader to transform their practice into a
medical home
Anand, S., MD, Physician Champion, National Initiative
for Children’s Healthcare Quality (NICHQ); Fitzgerald,
E., DrPH, Associate Director, NICHQ; Homer, C., MD,
CEO, NICHQ
L12: Knowledge Management
Strategies for Large-Scale
Improvement
Harbor Beach
Implementing effective learning strategies for
large-scale improvement programs is a challenge.
This Learning Lab will provide theory, practical
examples, and structured guidance on tested
strategies for successful large-scale learning.
Faculty will discuss strategies for face-to-face
learning as well as novel ideas about how to
move information and best practices around
and between dispersed participants in learning
networks. Lessons from the US, Scotland, and
Africa will be used to describe the models.
After this session, participants will be able to:
• Describe the framework that IHI uses for
knowledge management in large-scale projects
• Draw lessons and strategies from the IHI
experience in large-scale learning events and
learning platforms for dispersed participants
• Employ tools and methods for building
learning systems and knowledge
management platforms
Webster, P., Improvement Advisor, IHI; Lewis, N.,
Director, IHI; DeBartolo, K., National Field Manager, IHI
How is your Learning Lab? Tweet your thoughts using #IHI25Forum
9
PRE-CONFERENCE
L15: Person-Centered Health IT:
Making IT Happen
Grand Cayman/Puerto Rico
Sunday
DECEMBER 8
Learning Labs 1:00 PM-4:30 PM
L13: Lean Health Care Principles:
Interactive Diagnosis and
Problem-Solving F
Grand Ballroom, Salon 1-2
This interactive session will teach the principles of
Lean health care. Participants will start by viewing
a Flexsim Simulation video of a dysfunctional
emergency department. Teams of participants
will brainstorm and describe the various levels
of dysfunction. Teams will then brainstorm
solutions, and present them to the whole group.
The best-practice solutions, with implications
for a variety of health care settings, will be
discussed at the end of the session.
After this session, participants will be able to:
• Describe applications of Lean principles
and tools
• Evaluate a clinical scenario
• Apply Lean and flow principles
Crane, J., MD, Emergency Medicine Faculty, IHI;
Jensen, K., MD, Chief Medical Officer,
BestPractices, Inc.
L14: Mesosystems and Pathways:
Idealized Design
Crystal Ballroom, Salon E-F
Organizations are becoming more and more
aware of the need to improve, coordinate, and
design “mesosystems” of care—that is, two or
more microsystems and patient pathways. In this
session, participants will explore the essential skills
of assessment, creating community, leveraging
relationships across the organization, and
developing leadership.
After this session, participants will be able to:
• Identify and assess one mesosystem of care
• Practice designing and using the central data
room to drive innovation and the monitoring
of improvement
• Design an individual action plan to assess,
redesign, and monitor a mesosystem in
their organization
Godfrey, M., RN, Co-Director, The Microsystem
Academy, and Instructor, The Dartmouth Institute
for Health Policy and Clinical Practice; Downes, T.,
Consultant Geriatrician, Sheffield Teaching
Hospitals; McKinley, K., RN, Vice President,
Special Projects, Division of Quality and Safety,
Geisinger Health System
10
Many high-performing health care organizations
that truly focus on person-centered care are
increasingly exploiting health information
technology (IT) to support their efforts. Are you
wondering how health IT might improve the
services you offer to patients? Participants in
this session will consider what is generalizable
from the early adopters of health IT to support
patient-centered care and work together to
think through how their own organizations
might adapt lessons from leaders in the field.
After this session, participants will be able to:
• Describe the role health IT plays in
patient-centered care
• Appreciate the international experience of
patient-centered health IT
• Identify the key elements of patient-centered
health IT and assess their organization’s
progress against these elements
Robson, B., MB ChB, Executive Clinical Director,
Healthcare Improvement Scotland; Adams, L.,
President and CEO, Rhode Island Quality Institute;
Hunt, J., PharmD, Independent Consultant
L16: Rapid-Cycle Evaluation
for Improvement Leaders M
Crystal Ballroom, Salon A-C
It is crucial that health system leaders and
researchers who are testing improvement
interventions are able to evaluate and share
what they have learned. Improvement
interventions are often complex and can
change as the work unfolds, making evaluation
approaches complex. This session will use a
mix of presentations and participatory case
studies to explore a rapid-cycle evaluation
approach to learning from improvement
interventions and to share with others what’s
been discovered. Participants will be encouraged
to share ideas about their own work.
After this session, participants will be able to:
• Describe two methods for evaluating
improvement work
• Test the effectiveness of a quality improvement
intervention, both with and without the use
of comparison groups
Parry, G., PhD, Senior Scientist, IHI; Reid, A., Research
Associate, IHI; Cohen, S., MSW, Research Associate, IHI
Triple Aim for Populations
L17: Building the “ImproveCareNow”
Learning Health System P
West Indies
“ImproveCareNow” evolved from a small quality
improvement (QI) collaborative to a national
collaborative chronic care network and learning
health care system that engages patients,
families, clinicians, and researchers. In this
session, we will discuss how point-of-care data,
patient-reported outcomes, and innovative
technology create a robust registry not only
for QI (including patient activation, automated
pre-visit planning, and population management)
but also for research (including simulated clinical
trials) and innovation. Participants will have
an opportunity to learn about the dramatic
improvement in outcomes achieved.
After this session, participants will be able to:
• Describe how to develop a network of health
care organizations, patients, families, and clinicians focused on improving patient outcomes
• Leverage data for improvement, including the
concepts of a patient registry, “data-in-once”,
and the repurposing of data
• Identify ways to increase team efficiency in
a QI and research collaborative, including
automated reporting and the use of a
federated institutional review board
Crandall, W., MD, Professor of Clinical Pediatrics and
Associate Medical Director, Nationwide Children’s
Hospital; Margolis, P., Director of Research, James
M. Anderson Center for Health Systems Excellence,
Cincinnati Children’s Hospital Medical Center; Colletti,
R., Network Director, University of Vermont College
of Medicine; Moon, T., Parent Quality Improvement
Representative, Nationwide Children’s Hospital
L18: Changing Population Health:
Physician, Heal Thyself F
Miami
Unhealthy lifestyles contribute to increases
in health care costs at a time when resources
are severely strained. With obesity reaching
epidemic proportions, the challenge lies in
responding quickly and effectively. Bellin Health
and NHS Wales (UK) are tackling the problem
by addressing employee health with the aim of
impacting the wider population. Health care staff
are a significant element of the population, and
this challenge presents them with an important
leadership opportunity.
After this session, participants will be able to:
• Explain the link between employee health
and population health
• Describe two approaches that have been
undertaken to improve health behaviors
and reduce disease risks
• Explore how a targeted communications
campaign can contribute to successful
behavior change in participants
Knox, P., Executive Vice President, Bellin Health;
Kerwin, G., President and CEO, Bellin Health;
Cooper, A., Head of Communications and Marketing,
Public Health Wales; Willson, A., PhD, Director,
1000 Lives Plus, Public Health Wales
25th Annual National Forum on Quality Improvement in Health Care
L19: Improving Transitions from the
Hospital to Community Settings
L21: MiPCT: Michigan’s “Model T”
for Transforming Care
Grand Ballroom, Salon 3
Key Biscayne
The transition from the hospital to post-acute care
settings has emerged as an important priority in
reducing avoidable rehospitalizations. Hospitals
have an important role in designing and reliably
implementing effective discharge processes to
improve the transition from hospital to home or to
the next care setting. In this session, four research
and improvement initiatives that aim to improve
discharge processes in hospitals and reduce
rehospitalizations will be highlighted: IHI’s STAAR
(STate Action on Avoidable Rehospitalizations)
Initiative, the Society of Hospital Medicine’s
Project BOOST (Better Outcomes for Older
adults through Safe Transitions), the Agency
for Healthcare Research and Quality’s Project
RED (Re-Engineered Discharge), and the
Hospital to Home (H2H) initiative co-sponsored
by the American College of Cardiology and IHI.
This session will focus on how three diverse
practice organizations used a Centers for
Medicare and Medicaid Services (CMS)
demonstration project, the Michigan Primary
Care Transformation (MiPCT), to advance
care management within their organizations.
After this session, participants will be able to:
• Identify promising approaches for hospital
clinicians and staff to improve the transition
from the hospital to post-acute care settings
• Compare and contrast the strategies used
in the STAAR, Project BOOST, Project RED,
and H2H initiatives
• Identify the common elements of these
four initiatives
Rutherford, P., RN, Vice President, IHI; Jack, B., MD,
Professor and Chair, Department of Family Medicine,
Boston University School of Medicine; Nielsen, G.,
Fellow and Faculty, IHI; Horwitz, L, MD, Assistant
Professor, Yale University
L20: Primary Care Transformation
in Academic Medical Centers
St. Thomas
This session will highlight the experience of 18
primary care academic practices in their move
to full team-based care, empanelment, and the
care of populations—the foundations of robust
patient-centered medical homes. We will discuss
practical solutions to common problems in
academic settings, and patient/family and
residency training representatives will share their
experience as part of the transformation work.
After this session, participants will be able to:
• Identify successful strategies for setting
up primary care transformation in an
academic setting
• Describe practical strategies in the move
to team-based care and empanelment in
academic primary care practices
• Describe how to include patient input in
the work of primary care transformation
Sevin, C., RN, Director, IHI; Bitton, A., MD,
Associate Physician, Brigham and Women’s Hospital;
Sugarman, J., MD, CEO, Qualis Health; Pabo, E., MD,
Manager of Practice Improvement, Harvard Medical
School; Steinfield, R., Improvement Advisor, IHI
After this session, participants will be able to:
• Identify ways to leverage the electronic medical
record to facilitate care management and clinician communication across their organization
• Apply effective strategies to engage their team
• Optimize care management resources in a
multi-payer environment
Seguin, C., Director, Henry Ford Health System;
Sayers, D., DO, Regional Medical Director,
Northern Region, Henry Ford Health System;
Nicolaou, L., Care Manager, West Front Primary
Care; Bennett, K., Senior Quality Specialist,
Sparrow Medical Group
L22: Strategies for Managing
Populations: A Platform and
Portfolio Approach
Marco Island
The Patient Protection and Affordable Care
Act (ACA) has started a transition in the US
health care system from a focus on health care
production to population management. This
is leading health care systems to think about
what they need in order to be able to manage
populations. During this session, we will discuss
an overall approach to population management
based on research and development work at
IHI and knowledge gained from work in the
Triple Aim for the last eight years.
After this session, participants will be able to:
• Describe the population management
issues that hospitals face
• Apply the IHI framework to help them
manage the population they serve
Whittington, J., MD, Lead Faculty, Triple Aim Initiative,
IHI; Kabcenell, A., RN, Vice President, IHI; Ramsay, R.,
Director of Community Care, CareOregon
Person- and
Family-Centered Care
L23: ALL IN: Exceptional Patient
and Family Experiences M P
Grand Ballroom, Salon 11
We know that the relationships and experiences
of patients and families in health care are
key components of achieving the best overall
care outcomes in all health care settings. But
what steps should be taken to enhance these
relationships and experiences, and whose job is
it to do so? This session will describe the critical
aspects of strategic alignment; team engagement and skills for physicians, nurses, team
members, and patient advisors; individual and
team accountabilities; and infrastructure that
creates the best outcomes and the best work
environment.
After this session, participants will be able to:
• Describe the relationship between patient and
family experience and health care outcomes
• Identify and use the critical aspects of
strategic alignment
• Develop action plans to share with colleagues
Hayward, M., Lead, Patient and Family Engagement,
IHI; Balik, B., RN, Senior Faculty, IHI, Consultant,
Common Fire Healthcare Consulting; White, K.,
President, Aerate Consulting
L24: Coaching the Conversation
about End-of-Life Care
Key Largo
Are you eager to bring The Conversation
Project to your organization? During this session,
members of The Conversation Project team will
lead participants through a two-part framework
for leading Conversation Groups, offering them
the opportunity to practice with peers and
practice responding to difficult scenarios. In this
interactive session, as participants share ideas on
how they think about their own end-of-life care,
they will also reflect on and relate their personal
and professional experiences.
After this session, participants will be able to:
• Describe The Conversation Project and the role
of both health care providers and individuals in
discussing personal wishes for end-of-life care
• Develop an action plan that includes both
professional and personal conversations
• Identify the barriers to having the end-of-life
conversation and the strategies and tools
available to promote action
Warshaw, H., Executive Director, The Conversation
Project; McCannon, J., MD, Faculty, IHI; McCutcheon
Adams, K., LICSW, Director, IHI
L25: Perinatal Quality Model
Applications F
Crystal Ballroom, Salon P-Q
Beginning in 1995 with The Breakthrough Series,
organizations have partnered with IHI to improve
outcomes by improving structure and process.
Continuous learning on translational leadership and adult learning has driven new levels of
engagement with multidisciplinary stakeholders—
including patients and families. As the oldest such
learning community, IHI’s Perinatal Improvement
Community continues to push deeper into
new knowledge. In this session perinatal
faculty will share current knowledge on four
key areas—patient experience, health outcomes,
cost, and workforce.
After this session, participants will be able to:
• Identify opportunities to collaborate with and
engage health systems in their region or state
to improve outcomes for mothers and babies
• Apply knowledge that supports learning
and translational leadership
Cherouny, P., MD, Emeritus Professor, Obstetrics,
Gynecology, and Reproductive, University of Vermont;
Johnson, C., RN, Director of Obstetrics, Woman’s
Hospital; Gullo, S., RN, Director, IHI; Crowe, G., RN,
Principal, Hamilton Consulting, LLC
How is your Learning Lab? Tweet your thoughts using #IHI25Forum
11
PRE-CONFERENCE
Sunday
DECEMBER 8
Learning Labs 1:00 PM-4:30 PM
After this session, participants will be able to:
• Discuss the unique safety challenges in
ambulatory settings
• Describe tools for developing teamwork in
ambulatory practices
• Identify two methods for capturing
and analyzing harm and error in an
ambulatory setting
Haraden, C., PhD, Vice President, IHI; Gandhi, T., MD,
President, National Patient Safety Foundation (NPSF)
L28: Improving the Flow of Resident
and Hospitalist Work
Aruba/Bahamas
L26: The Disparities Leadership
Program: Implementing Strategies
to Address Disparities
Anaheim
The Disparities Leadership Program (DLP)
is a year-long executive education program
designed to assist health care leaders with
developing a strategic plan or project to eliminate
racial and ethnic disparities in their health care
organizations. In this session, we will discuss
the barriers and challenges to advancing and
implementing strategies to address disparities,
the role of the DLP framework in translating
research findings into implementation, and
examples of success in the DLP approach
to addressing health disparities.
After this session, participants will be able to:
• Recognize the root causes of disparities
in the quality of care
• Describe the approaches taken by some
health care organizations to identify and
address racial and ethnic disparities
• Discuss the challenges, successes, and next
steps in addressing health care disparities
Betancourt, J., MD, Director, The Disparities Solutions
Center, Massachusetts General Hospital (MGH);
Tan-McGrory, A., Deputy Director, MGH; McCracker, K.,
Director of Operations, Manchester Community
Health Center
Patient Safety
L27: Creating a Culture of Safety in
an Ambulatory Care Setting
Grand Ballroom, Salon 4-6
Improving safety and culture has long been the
work of hospitals, but most people receive the
majority of care over their lifetime in ambulatory
settings, where the work is different and so are
the safety challenges. Methods of improving
safety and culture in acute care settings are not
always appropriate for ambulatory practices. The
methods used to capture, analyze, and reduce
harm and error must match the work and be
usable by the ambulatory team. In this session,
participants will learn how creating an ambulatory
care environment where risks are anticipated,
teamwork is standard, and patient partnerships
are maximized allows a culture of safety to flourish.
12
Hospital teaching rounds are a time-honored
tradition and a fundamental aspect of residency
training. In most institutions, the basic format
of rounds has not changed for decades. In this
session, we describe how Virginia Mason Medical
Center improved the work flow of residents and
hospitalists by applying the principles of the Virginia Mason Production System. Morning rounds
were redesigned to allow residents to complete
high-quality and timely patient care, one patient
at a time.
After this session, participants will be able to:
• Recognize the impact of batch rounding on
the clinical operations and educational
experiences of hospitalists and residents
• Demonstrate the differences between batch
rounding and one-piece flow rounding
• Plan a cycle of improvement to reduce
batching in their hospital rounds
Calderon, A., MD, PhD, Program Director, Internal
Medicine Residency Program, Virginia Mason Medical
Center; Hanson, D., Hospital Medicine Director of
Quality and Safety, Virginia Mason Medical Center
L29: Integrating Patient Safety
into Your System’s DNA F
Grand Ballroom, Salon 12-14
Since the beginning of the new millennium,
research on topics related to patient safety has
led to numerous solutions that could make care
processes more reliable and improve patient
outcomes. Implementation, however, has
lagged behind, and global progress has been
disappointing. In this session, participants
will study and discuss the components of an
institutional improvement program, with an
emphasis on system-wide implementation
and sustainability.
After this session, participants will be able to:
• Describe the key components of an
institutional patienty safety
improvement program
• Articulate how some organizations have
implemented these components
• Discuss how to develop a culture of safety
and continuous learning
Federico, F., RPh, Executive Director, Strategic
Partners, IHI; Peden, C., MB ChB, MD, Associate
Medical Director for Quality Improvement,
Consultant in Anesthesia and Intensive Care,
Royal United Hospital, Bath; Staines, A., PhD,
Associate Professor, University of Lyon
L30: Intelligent Measurement
for Intelligent Boards
Chicago/Denver
Measures of patient safety, including adverse
incident reporting and global trigger tool reports,
are often supplemented with other process
and outcome measures to develop dashboards.
In this session, we will review the available tools
for measuring harm, the essential elements of
a safety dashboard, the ways in which dashboards measure harm, the pitfalls of current
approaches, and new composite measures of
harm. Innovations in safety measurement will
also be presented and discussed.
After this session, participants will be able to:
• Describe both advantages and limitations of
the current approaches to measurement
taken by CEOs and boards
• Discuss the essential elements of a safety
surveillance system that can optimize
oversight by senior leaders and boards
• Identify the skills and support required by
boards to actively measure and monitor safety
Dalton, D., Chief Executive, Salford Royal Hospital
Foundation NHS Trust; Power, M., Director, Salford
Royal Hospital Foundation NHS Trust
Sunday
SPECIAL EVENT
International Attendee Meeting
5:00 PM – 7:00 PM
Crystal Ballroom, Salon D
All National Forum attendees are invited to take advantage of this informal opportunity to
network with international peers who are working on health systems improvements around
the world and hear about the strategic vision and current execution of IHI’s global work.
25th Annual National Forum on Quality Improvement in Health Care
PRE-CONFERENCE
Monday
DECEMBER 9
National Forum
Orientation
7:00 AM – 8:00 AM
FE2: Universal Orlando®:
Safety and Reliability
G Gaylord Palms: Sun Ballroom 5-6
FE6: Gaylord Palms: Joy in Work
and Customer Satisfaction
G Gaylord Palms: Sanibel
Sword fights…staged gun shots…boat
explosions…What do these have in common
with patient safety and reliability in health care?
Learn how the Universal stunt team ensures
safety of staff and visitors during high-risk
stunts and addresses reliability when there
are handoffs and staffing changes as well as
what they do when unexpected events occur.
Stunt actors will demonstrate how they
routinely focus on the Universal Orlando®
culture of “safety first.”
Customer satisfaction starts with staff
satisfaction at this large hotel and convention
center. In studying how the Gaylord Palms
handles staffing assignments, manages
unprofessional behavior, and keeps employee
attrition rates lower than the industry standard,
participants will learn best practices for
incorporating “joy in work.”
Lloyd, R., PhD, Executive Director, Performance
Improvement, IHI; Griffin, F., Faculty, IHI
FE7: Darden Restaurant Group
G Gaylord Palms: Captiva
FE3: Central Florida Zoo:
Patient Care and Operations
G Gaylord Palms: Tallahassee 1-2
If you are new to the National Forum, we
suggest that you attend one of the National
Forum Orientation sessions to help you
navigate through the program and devise
a personal learning plan. Participation in
a National Forum orientation is free.
Behind the scenes of the Central Florida Zoo,
we will discover examples of key efficient safety
processes as they care for over 400 very special
“patients.” Participants will learn details of
the zoo’s operations, safety protocols (for both
humans and wildlife), and crisis management
planning. Zoo staff will also share their methods
of caring for, feeding, and managing many
types of animals at once.
Forum Excursions
Duncan, K., RN, Faculty, IHI; Bell-Polson, D.,
Director of Maternal Child Health, Lawrence
General Hospital
Crystal Ballroom, Salon G
8:30 AM – 5:00 PM
With the exception of the Marriott Excursion
(FE1), all Excursions start at the Gaylord Palms
Resort and Convention Center. Participants will
then be transported to their selected destination
for a three-hour tour and presentation led by
destination staff and IHI faculty. Afterward,
participants will explore the lessons learned
and their applicability to health care during
an afternoon “deep dive” led by IHI faculty.
FE1: Marriott World Center:
Manage Large-Scale Operations
Marriott World Center: Key West
Participants will learn how the Marriott
manages the processes for ensuring efficient
flow/throughput of large volumes of visitors, yet
still manages to offer superb customer service in
the front office; adhere to tight schedules in the
banquet kitchen; run a golf club; tend to every
detail of event and convention services; and
manage daily housekeeping operations.
Gullo, S., RN, Director, IHI; Loehrer, S., MD,
Director, IHI
FE4: LEGOLAND Florida: Managing
Complex Adaptive Systems
G Gaylord Palms: Sun Ballroom 1-2
See for yourself how this popular destination,
new to Orlando, manages complex processes
to engage, teach, and entertain thousands
of children and adults every day. Meet with
managers responsible for sales, visitor
experience, and lego model building.
Participants will also have an opportunity
to meet with corporate leaders to learn about
and discuss strategies for managing the
complex, adaptive systems that exist
within LEGOLAND.
Gunther-Murphy, C., Director, IHI; Dickson, E., MD,
President and CEO, UMass Memorial Health Care
Darden is the world’s largest full-service
restaurant company with annual sales of
$8 billion, and their family of restaurants
includes Red Lobster, Olive Garden, Longhorn
Steakhouse, Bahama Breeze, Seasons 52, The
Capital Grille, Eddie V’s and Yard House—2,100
North American locations in all. Recognized for
its commitment to diversity and sustainability,
Darden also has been named to the Fortune
“100 Best Companies to Work For” list for the
past three years. In this interactive Excursion,
Darden executives, including President Eugene
Lee, will discuss the company’s multi-brand
strategy, talent and culture management,
marketing and branding, use of social media,
food procurement and safety, and community
and government affairs.
Swensen, S., MD, Medical Director, Leadership
and Organizational Development, Mayo Clinic;
Berry, L., PhD, Distinguished Professor of Marketing,
Texas A&M University
On Monday morning, shuttle buses will be
available to the Gaylord Palms from all
National Forum hotels.
Bones, K., MSW, Project Director, IHI; Levy, P., Author
FE5: EA SPORTS – Tiburon:
Innovation and Creativity
G Gaylord Palms: Sun Ballroom 3-4
Join the leaders in the video game industry as
they describe how they foster an environment of
continuous innovation and creativity. Members
of IHI’s Innovation Team will guide participants
as they hear about EA SPORTS – Tiburon’s new
product design processes, learn about their
methods for keeping pace with customer
preferences, and explore their approach of
team engagement.
Johnson, M., Senior Research Associate, IHI;
Moses, J., MD, Director of Safety and Quality,
Department of Pediatrics, Boston Medical Center
How is your Forum Excursion? Tweet your thoughts using #IHI25Forum
13
PRE-CONFERENCE
Monday
DECEMBER 9
Virtual Site Visits
Morning Visits: 8:30 AM – 12:00 PM
Afternoon Visits: 1:00 PM – 4:30 PM
Virtual Site Visits allow attendees to gain an
in-depth understanding of how improvement work
is accomplished within best-practice organizations
via virtual tours and video interviews with front-line
staff and leadership. Attendees will choose two
organizations to visit virtually.
Morning Virtual Site Visits
VSV1: Jönköping and
Qulturum, Sweden
Anaheim
Jönköping County Council is a health care system
with the responsibility to provide health care,
medical treatment, and dental services for the
residents within Jönköping County, Sweden. This
session will focus on the strategic goals identified
by the by Jönköping County Council as key areas
to improve health care and increase the value of
the services for the patients and population. The
drive for improvement in these areas is supported
by Qulturum. Qulturum is a center for learning
and transformation of care and its main focus is
on facilitating improvement in the fields of patient
involvement, prevention, cooperation, clinical
improvement, and safety, coaching teams,
and designing health care services.
After this session, participants will be able to:
• Describe the key areas to improve health and
increase the value of services as identified by
Qulturum in Sweden
• Identify best practices that can be brought
back to their organizations
Henriks, G., Chief Executive of Learning and
Innovation, The County Council of Jönköping;
Rukat, A., Coordinator, Qulturum, Sweden
VSV2: Bellin Health System
Crystal Ballroom, Salon E-F
The Bellin Health virtual site visit will focus on the
high-performance health care model. This model
consists of aligning six dimensions: Strategic
clarity; production system design; measurement
system design; improvement/innovation; sales/
marketing; and culture. This business model
14
aligns and deploys strategy to achieve results.
In the high-performance model, the shift is away
from activity, towards an execution framework
that maximizes organizational energy around
high-leverage priorities necessary for achieving
strategic results. In this presentation, this model
will be presented using a mix of video and
verbal discussion.
After this session, participants will be able to:
• Describe the six dimensions of the high
performance health care model
• Identify best practices that can be
brought back to their organizations
• Explain the framework for managing
priorities and making decisions about
organizational focus
Kerwin, G., President and CEO, Bellin Health;
Knox, P., Executive Vice President, Bellin Health
VSV3: Kaiser Permanente
Crystal Ballroom, Salon P-Q
If you could imagine the future of health care,
what would it look like? At Kaiser Permanente,
we are committed to helping shape the future of
health care. This presentation will explore how
our journey to transform health care began with
our mission, the will of leadership, and listening
to our patients. From there, we worked across
the organization—from the front-line to executives—to develop ideas that improve the care we
deliver. Finally, we executed on systems to drive
these improvements. This session will explore the
role of physician engagement and leadership in
this transformation. Additionally, participants will
discuss whether excellence is good enough in the
current environment. Finally, this Virtual Site Visit
will examine how Kaiser Permanente is leveraging
learning and using our excellent performance as
a platform to accelerate improvement for our
9 million members.
After this session, participants will be able to:
• Extract key elements from Kaiser’s journey
that could be applied to their system
• Identify best practices that can be brought
back to their organizations
• Consider when excellence is not enough
and the need to shift from celebration
to acceleration
Chase, A., Senior Vice President, Medicare Clinical
Operations and Population Care, Kaiser Permanente;
Cochran, J., MD, Executive Director, The Permanente
Federation
VSV4: Memorial Hermann
Health System
Chicago/Denver
Learn how Memorial Hermann rebooted its quality
and safety program in 2006 to adopt the secrets
of High-Reliability Organizations (HROs). Explore
the HRO techniques developed in industries
like air traffic control, commercial aviation, and
nuclear submarines that work perfectly in the
health care environment. Learn why all employees
(over 20,000 at Memorial Hermann) had to learn
high-reliability techniques for the safety culture to
flourish. Hear from Memorial Hermann’s Board of
Directors about why they made patient safety the
health system’s single core value. Virtually visit
our care units to see how this works on the frontline and how to develop processes for high-risk
procedures like blood transfusion with better
than Six Sigma reliability. Lastly, learn how this
applies to our rapidly growing Accountable
Care Organization, now with over 300,000
attributed lives.
After this session, participants will be able to:
• Describe why high-reliability is the ultimate
quality and safety goal for health care
organizations
• State why high-reliability health care has been
difficult to achieve in the past, and how they
can help achieve it now
• Demonstrate how a new safety culture can
be developed over time with HRO techniques
Shabot, M., MD, Senior Vice President and
System Chief Medical Officer, Memorial Hermann;
Wolterman, D., President and Chief Executive
Officer, Memorial Hermann
VSV5: Henry Ford Health System
Miami
In 2003, Henry Ford Health System (HFHS)
leadership decided to pursue organizational
integration to deliver the best care to HFHS
patients and drive sustainable growth. CEO
Nancy Schlichting set the path toward improving
performance throughout the system, electing to
adopt the Baldrige Criteria for Performance
Excellence as a strategy for change. This Virtual
Site Visit to HFHS offers an in-depth view of
key changes made in the leadership system;
workforce development and communication;
strategic planning process; performance
improvement tools and measures; the redesign
of work systems and processes—including the
new 200-bed Henry Ford West Bloomfield
Hospital—and the creation of a culture of patient
safety. These helped lead to improved patient
satisfaction, employee engagement, and
reduction in harm events and inpatient mortality.
Since embarking on the performance excellence
journey, HFHS has received five national performance awards, including the Malcolm Baldrige
National Quality Award in 2011.
After this session, participants will be able to:
• Describe key changes made at HFHS
after adopting the Baldrige Criteria for
Performance Excellence
• Identify best practices that can be
brought back to their organizations
Conway, W., MD, Executive Vice President and
Chief Quality Officer, HFHS and CEO, Henry Ford
Medical Group; Swanson, J., Vice President,
Performance Analytics and Improvement, HFHS;
Schreiber, M., MD, Senior Vice President, Clinical
Transformation and Associate Chief Quality
Officer, HFHS
25th Annual National Forum on Quality Improvement in Health Care
Afternoon Virtual
Site Visits
VSV8: Gundersen Lutheran
Health System
VSV6: Cincinnati Children’s Hospital
Medical Center
Anaheim
How does a health system achieve
transformation? Cincinnati Children’s Hospital
Medical Center (CCHMC) is deeply committed
to improving health outcomes for children—
beginning with senior leadership, and creating
a culture of improvement throughout the
organization, linking leaders to the front line.
CCHMC has been on a journey of transformation,
learning much in the process. This Virtual Site
Visit will cover the key factors in successful health
system transformation through principles such
as improvement science, discovery, systems
thinking and integration, caring, transparency,
and resiliency. Key leaders from CCHMC will
discuss how they translate these ideologies
into action every day to improve health
outcomes for children.
After this session, participants will be able to:
• Identify the critical factors in the
transformational journey at their
health system
• Discover how their organization can
leverage the dynamics of an improvement
culture to deliver reliably on operations
• Identify tactics to expand their reach
into the community to broadly improve
children’s health outcomes
Kotagal, U., SVP, Quality and Transformation and
Director, Health Policy & Clinical Effectiveness,
CCHMC; Fisher, M., President and CEO, CCHMC;
Ryckman, F., Senior Vice President, Medical
Operations, CCHMC; Margolis, P., MD, PhD, Director
of Research, James M. Anderson Center for Health
Systems Excellence, CCHMC;
VSV7: Mayo Clinic
Crystal Ballroom, Salon E-F
This session will allow attendees to participate
in a conversation with Mayo Clinic about how
legacy, heritage, values, innovation, systems, and
culture drive quality improvement. Join organizational leaders in a discussion about Mayo Clinic’s
approach to improving the quality of integrated,
patient-centered health care.
After this session, participants will be able to:
• Share the mechanics of how providers work
together to coordinate patient care
• Describe how Mayo Clinic’s primary value “the
needs of the patient come first” is the heart of
employee engagement
• Implement a best practice for advancing quality
within their organization
Dilling, J., Senior Administrator, May Clinic;
Santrach, P., MD, Chair, Quality Oversight, Mayo Clinic
Crystal Ballroom, Salon P-Q
Gundersen Health System is committed to
delivering high quality care because lives depend
on it; service as though the patient were a loved
one; and relentless improvement because our
future depends on it. Bringing hope and health
to our loved ones who face the most difficult
diagnoses with no sleepless nights was the
concept that pushed us to transform care.
This presentation will explore Gundersen’s
journey to transform care. Faculty will present
through our patient Margie’s eyes as she moved
from diagnosis, to treatment, and then to recovery
from breast cancer. Faculty will explore examples
and explanations of how we bring to the patient
the best continuum of integrated care across
multiple disciplines using a holistic, patientcentered approach. Finally, presenters will share
how their medical and administrative leadership
model and managements systems develop,
drive, and sustain improvements.
After this session, participants will be able to:
• Describe the execution of multidisciplinary
holistic care along a timeline that meets the
needs of patients and families
• Identify best practices that can be brought
back to their organizations
Barton, K., Vice President, Operations, Gundersen
Health System; Bintz, M., MD, Vice President,
Gundersen Health System
VSV9: 2012 Baldrige Winners:
North Mississippi Health System
and City of Irving, Texas
Chicago/Denver
The Malcolm Baldrige National Quality Award
recognizes US organizations in the business,
health care, education, and nonprofit sectors
for performance excellence. The Baldrige
Award is the only formal recognition of the
performance excellence of both public and
private US organizations given by the President
of the United States. In 2012, four organizations
received this prestigious award. Join two of the
four organizations—North Mississippi Health
Services and the City of Irving, Texas—in a
virtual tour of their respective organization.
After this session, participants will be able to:
• Identify lessons learned from the
Baldrige journey
• Glean strategies that could improve their
organization’s performance
Moderator: Parsons, T., Vice President, Tennessee
Hospital Association
Presenters: Cummings, O., PhD, Chief Strategy
Officer, North Mississippi Health System;
Boyd, L., Chief of Police, City of Irving, Texas
Scientific Symposium
on Improving the
Quality and Value
of Health Care
8:30 AM – 5:00 PM
G Gaylord Palms Resort and
Convention Center, Sun Ballroom A-B
$300
The Scientific Symposium
features rapid-fire presentations
of peer-reviewed papers, with
an afternoon storyboard session.
This program will include keynote
presentations by Lisa Simpson,
MB BCh, MPH, President and
CEO of AcademyHealth and
Carolyn Clancy, MD, Assistant
Deputy Undersecretary for
Health, Quality, Safety, and
Value, Veterans Health
Association; Former Director
of the Agency for Healthcare
Research and Quality (AHRQ).
What are you talking about during your Virtual Site Visit? Tweet it using #IHI25Forum
15
PRE-CONFERENCE
Monday
DECEMBER 9
Minicourses
8:30 AM – 4:00 PM
Minicourses offer in-depth, hands-on learning
opportunities and many take-home tools for
implementing and sustaining change.
Quality, Cost, and Value
M1: Leadership Required
for the New Era M
Grand Ballroom, Salon 3
Health care leaders are under increasing scrutiny
as they seek to improve the quality and cost of care
for the populations they serve. For these leaders,
health care reform has made the need to decrease
costs—while increasing the organization’s scope
of service and improving the quality of services—
even more urgent. Strong leadership is essential
if health care organizations are going to thrive in
tomorrow’s emerging health care environment.
IHI’s Leadership Model describes the five domains
of action for leaders that move organizations
toward improvement, innovation, and successful
adaptation to the imperatives of health care reform.
After this session, participants will be able to:
• Discuss the challenges facing today’s
health care leaders
• Describe the five domains of the IHI
Leadership Model, their importance to
achieving organizational success, and
the vital behaviors of leading health care
chief executives in each of these domains
• Identify methods for applying the IHI Leadership
Model in their organization and fostering these
vital behaviors in their leadership team
Kabcenell, A., RN, Vice President, IHI; Pugh, M.,
President, MdP Associates, LLC; Balik, B., RN,
Senior Faculty, IHI, Consultant, Common Fire
Healthcare Consulting
16
Faculty will focus on ways to effectively integrate
aims and outcomes (quality, cost, service,
satisfaction) and enhance value to achieve
savings in annual operation costs. Through the
use of mock board meetings, participants will
have the opportunity to wrestle with some of the
most difficult problems faced by boards and to
learn about best practices to overcome them.
After this session, participants will be able to:
• Describe a framework for understanding a
board’s role in overseeing quality and safety
• List three changes they could apply to improve
their board’s oversight of quality and discuss
three innovative best practices that their
board could implement
• Identify specific opportunities to decrease
direct costs while improving quality
Orlikoff, J., President, Orlikoff & Associates, Inc.;
Benjamin, E., MD, Senior Vice President and Chief
Quality Officer, Baystate Health
Improvement Capability
M3: A Crash Course in Social
Media for Improvement F
Marco Island
Across the globe, leaders in health care quality
improvement efforts are using Twitter and
other social media to gain knowledge, share
experiences, connect with patients, and influence
others on a scale we could not have imagined a
few years ago. The ability to tweet, for instance,
is fast becoming a critical skill in the quality
improvement toolkit. This session will equip
participants with the basic skills needed to use
Twitter and other social media as a transformative
force. For anyone new to Twitter or social media,
this Minicourse is an outstanding opportunity to
learn skills in an accelerated way to help achieve
improvement goals.
After this session, participants will be able to:
• Use social media confidently and effectively
to support their daily health care
improvement work
• Identify the key components of effective and
innovative social media campaigns that have
changed the world, with an eye to how such
campaigns can be applied to health
care improvement
• Appreciate the untapped energy source
available through social media tools
Krause, C., Krause, C., Executive Director, British
Columbia Patient Safety and Quality Council
(BCPSQC); Puri, A., Quality Leader, Communications
and Engagement, BCPSQC; Smith, K., Digital Media
and Communications Specialist, BCPSQC
M2: The Role of the Board
in Quality and Safety M
M4: Accelerating Health Care
Transformation with Lean and
Innovation: The Virginia Mason
Experience
Sawgrass
Grand Ballroom, Salon 7
This session will describe the role of
governance—executive and clinical
leadership—in overseeing quality and
safety through an IHI framework.
It’s time to dispel myths like the belief that
Lean and concepts such as standard work are
“anti-innovation.” Drawing on the experience
of Virginia Mason Medical Center—as well as
general innovation theory and its application—the
presenters in this Minicourse will describe how
Lean and innovation can coexist in a health
care organization and intertwine to create a
powerful approach that deepens and accelerates
improvement. Participants will be given concrete
examples of how specific innovation and creativity
methods can be integrated into Lean
implementations.
After this session, participants will be able to:
• Support their organization’s implementation
of Lean methods through culture change and
application of innovation concepts and tools
• Recognize opportunities to apply creative
thinking in a more deliberate way within the
context of a chosen improvement approach
such as Lean
• Describe how Virginia Mason has integrated
innovation and Lean to accelerate its quality
and safety improvement efforts
Chafetz, L., JD, SVP, Virginia Mason Medical Center;
Phillips, J., Director of Innovation, Virginia Mason
Medical Center; Plsek, P., Consultant, Paul E.
Plsek & Associates, Inc.; Tufano, A., Faculty,
Virginia Mason Institute
M5: Advanced Statistical
Process Control in Health Care M
Crystal Ballroom, Salon K-M
This Minicourse will cover several issues in
statistical process control (SPC) in health
care. After a brief review of the basics (types
of data, basic control charts, choice of chart,
interpretation), the presenters will discuss how
to assess performance (such as how to detect
important changes), and how to improve
performance, especially with respect to sample
size, chart design, and exponentially weighted
moving average (EWMA) and cumulative sum
control (CUSUM) charts. Case studies will
be presented that illustrate both issues in
measurement error (theory, concepts, impact,
action) and, more specifically, common errors
in health care applications of SPC.
After this session, participants will be able to:
• Assess and improve the effectiveness of
SPC tools
• Use rare event charts, EWMA charts,
and CUSUM charts
• Avoid common errors and mistakes in
applying SPC to health care
Jordan, V., PhD, Director, Quality Measurement and
Engineering, University of Texas MD Anderson Cancer
Center; Benneyan, J., PhD, Professor, Northeastern
University; James, B., MD, Chief Quality Officer,
Intermountain Healthcare
M6: Courage in Health Care:
Leading from Within F
Grand Ballroom, Salon 1-2
Change calls for personal and communal
courage. This program introduces current and
emerging health care leaders (Open School
students encouraged) and patient advocates to
the Center for Courage & Renewal’s principles
and practices for leading from within. The
Courage & Renewal® approach supports
25th Annual National Forum on Quality Improvement in Health Care
professional renewal and leadership integrity.
Attendees will learn Parker Palmer’s “Habits
of the Heart,” which help leaders and groups
hold tension in generative ways and support
the building of relational trust and responsible
decision-making.
• Apply lessons from system-, national-, and
international-level examples to their spread efforts
After this session, participants will be able to:
• Identify three ways to foster engaged
listening and attention
• Implement protocols for reflection and
connection in groups
• Name the “Habits of the Heart” that support
relational trust in effecting positive change
M9: Making High-Reliability
Health Care Happen
Schall, M., Senior Director, IHI; Mate, K., MD, Vice
President, IHI; Haraden, C., PhD, Vice President, IHI;
McCannon, J., Faculty, IHI
Crystal Ballroom, Salon N
Kinkead, L., Consultant, The Collabrium; Lenarz, L.,
MD, Medical Director, Clinician Professional
Development, Fairview Health Services
M7: Data Sanity: Leadership
Catalyst to Transformation
Crystal Ballroom, Salon G
Poor use of data remains a major—and invisible—
source of waste. What if executives and middle
managers facilitated transformation by spending 50
percent less time in meetings pouring over routine
published operational and financial data (60 to 80
percent of which is waste?) This session will teach
“data sanity”—an organization-wide everyday
language used in conjunction with results-oriented
facilitation skills. This innovative approach to
leadership integrates improvement into the cultural
DNA and encourages physician participation.
After this session, participants will be able to:
• Identify the key elements of data sanity that
everyone needs to be taught—especially the
common and special causes of variation
• Apply four techniques to focus vague problems,
reduce cultural defensiveness, and encourage
appropriate participation
• Apply basic results-oriented coaching skills
and cultural psychology to integrate data sanity
effectively as an organizational language for
continual improvement
Balestracci, D., Statistician and Quality Improvement
Specialist, Harmony Consulting, LLC
Several organizations are working to develop
effective strategies and tools to adapt lessons
from high-reliability organizations that can be
used effectively in health care. For hospitals and
health systems to achieve high-reliability, they
will need to ensure three critical components.
These are: A leadership commitment to achieve
the ultimate goal of zero patient harm; a strong
and vibrant culture of safety; and the adoption
and widespread deployment of highly effective
process improvement tools. This Minicourse is
designed for Chief Medical Officers and Chief
Quality Officers, who are critical leaders on the
journey to high reliability health care. Attendees
will hear from faculty who are deeply engaged
in this work and will share their experiences
and facilitate an interactive discussion.
After this session, participants will be able to:
• Discuss the importance of leaders as agents
of change on the journey toward high reliability
• Share lessons learned from those who are
working to achieve high reliability
• Articulate specific actions they can take
within their organizations to make progress
toward high reliability
Chassin, M., MD, President, The Joint Commission;
Yates, G., MD, President, Sentara Quality Care Network
and Healthcare Performance Improvement, LLC,
Sentara Healthcare; James, B., MD, Chief Quality
Officer, Intermountain Healthcare; Berwick, D.,
MD, President Emeritus and Senior Fellow, IHI;
O’Shaughnessy, P., DO, Senior Vice President of
Medical Affairs and Chief Medical Officer, Catholic
Health Services of Long Island; DuPree, E., MD,
Chief Medical Officer and Vice President, Joint
Commission Center for Transforming Healthcare
M8: Going Full-Scale: Taking a Fresh
Look at Approaches to Spreading
Improvements
M10: How to Be a Great
Change Agent M
Crystal Ballroom, Salon A-C
It’s tough being a change agent, particularly
when other people don’t want to change. Yet
big change happens in health care organizations
only because of heretics: Passionate people who
are willing to take responsibility for change. Such
individuals support organizational goals, but also
want to change existing thinking and practice
and improve care for patients. This session
provides a toolkit for surviving and thriving as
a change agent.
Crystal Ballroom, Salon D
Scale-up thinking—finding and overcoming the
infrastructure issues that arise during spread—
gives us an added dimension to consider in leading
the large-scale spread of improvements. Whether
change is spread at a facility, system, community, regional, or national level, crucial tasks in a
successful spread effort include establishing clear
aims, engaging leaders, and identifying the tools,
resources, and processes needed to motivate
adopters and support implementation of the
improvement at each stage in the development
of the change. In this session, examples from
large-scale spread efforts will be used to illustrate
the power of scale-up thinking.
After this session, participants will be able to:
• Build scale-up thinking into the design of
large-scale spread initiatives
After this session, participants will be able to:
• Identify and practice tactics for being
an effective change agent
• Build a toolkit of powerful approaches
to enable change
• Connect with and learn from other
change agents
Bevan, H., PhD, Chief of Service Transformation,
NHS Improving Quality; Varnam, R., MD, PhD,
Primary Care Physician, NHS Institute for
Innovation and Improvement
M11: Integrate Words and
Numbers to Improve Action F
Grand Cayman/Puerto Rico
The integration of both qualitative and
quantitative data can provide a more inclusive
and useful understanding of a system,
subsystem, or project. With better understanding,
a more consequential story—and hence better
informed action—can be developed. In this
interactive session, participants will explore
processes to support effective collection and
analysis of qualitative data, using modified
methods from qualitative research to synthesize
this information from patients with traditional
quantitative data. This helps to develop
a more meaningful and constructive story.
After this session, participants will be able to:
• Identify ways to effectively collect and
analyze qualitative feedback from patients
• Use modified methods to integrate the
findings of qualitative research with traditional
quantitative data to construct a meaningful story
Butts, S., Improvement Advisor, Butts-Dion
Consulting, Inc.; Taylor, J., Improvement Advisor, IHI;
Crowe, G., RN, Principal, Hamilton Consulting, LLC
M12: Managing Improvement at the
Front Line
Grand Ballroom, Salon 11
Although front-line managers play a critical
role in supporting, executing, and sustaining
improvement and patient safety, many may
lack the necessary fundamental improvement
competencies and are burdened with
unanticipated daily problems, excessive
demands, and inefficient systems. In this
session, participants will acquire tools to help
them manage time, solve problems more
effectively, and enhance their skills in
effective measurement systems and
improvement processes.
After this session, participants will be able to:
• Identify the foundational tools that managers
must have to support improvement
• Describe two measurement approaches
to tracking improvement progress
• Use new skills in coaching and collaborative
leadership models
Williams, D., PhD, Improvement Advisor, TrueSimple
Consulting; Munch, D., MD, Executive Vice President,
Healthcare Performance Partners
M13: See, Solve, Share, and Lead:
Methods for Achieving Excellence F
Grand Ballroom, Salon 12-14
This Minicourse will introduce the capabilities
that underpin the sustained competitive advantage of high-velocity organizations. Participants
will learn to see (identifying process deviations in
(continued on next page)
What are you talking about during your Minicourse? Tweet it using #IHI25Forum
17
PRE-CONFERENCE
Monday
DECEMBER 9
Minicourses 8:30 AM-4:00 PM
flagging systems before they reach failure points);
solve (addressing, rectifying, and converting
failures into sources of superiority); share
(understanding the internal dynamics of a
high-velocity organization to ensure knowledge
spread for relentless improvement); and lead
(identifying the critical skills and leadership
roles in high-velocity organizations.)
After this session, participants will be able to:
• Implement “see, solve, share, and lead”
methods for performance improvement
• Differentiate between complicated and complex dynamics in high-velocity organizations
Downes, T., Consultant Geriatrician, Sheffield Teaching
Hospitals; McIlwain, T., MD, Vice President, Quality
and Process Improvement and Chief Medical Officer,
St. Luke’s Episcopal Hospital; Spear, S., Senior Fellow,
Massachusetts Institute of Technology
M14: Systems Simulators:
The Theory and Practice M
St. Thomas/West Indies
There are simulators for readmissions, spread,
and access, and all of them help teams test out
various change strategies and discover the likely
impact and result they can expect if they follow
the strategy. These simulators are crucial when
the variables are complex and interdependent,
and when results can be expected only at some
time and distance from the implementation of the
change strategies. Systems simulators are new
to health care and are becoming an essential
part of large complex systems change.
After this session, participants will be able to:
• Describe the theory of gaming and simulation
and how it relates to social learning
• Assess different gaming and simulation
methods and scope out ideas for their own
computer-based simulation or game
• Identify, test, and critique the ways in
which systems simulation can speed up
the implementation of systems improvement
Fraser, S., PhD, Independent Consultant, Sarah
Fraser & Associates Ltd; Henriks, G., Chief Executive
of Learning and Innovation, The County Council
of Jönköping; Thompson, K., Managing Director,
Bioteams Design
18
Triple Aim for Populations
• Draw lessons from VMMC’s experience that
can be applied to their own organization
M15: Designing for Health and
What Matters Most: Value-Based,
Whole-Person Systems of Care
Silversin, J., DMD, DrPH, President, Amicus, Inc.;
Kaplan, G., MD, Chairman and CEO, VMMC
Grand Ballroom, Salon 9-10
M17: IHI’s Approach to Reducing
Avoidable Readmissions
In this creative course, participants will design
community centers of health that honor, enhance,
and produce value through robust primary care
team relationships, building on Intermountain
Health’s successful and sustained redesign of
primary care through mental health integration
(MHI), IHI’s Triple Aim, and the development of
integrated care for dually eligible beneficiaries.
Participants will create a framework that defines
value by incorporating an understanding of what
really matters to individuals, their families, and their
communities; describes the leadership needed
to deliver this value; and provides approaches
to practical measurement of success in meeting
those values. Participants will engage in a collective
social network activity that creates novel designs
for sustainable, local, and affordable social centers
of health, focusing on efficient, evidence-informed
care processes, realigned financial incentives,
and engagement of patients, families, and
communities. They will also create a set of
implementation and measurement tools to apply
to their own local health delivery transformations.
Grand Ballroom, Salon 8
After this session, participants will be able to:
• Create a set of values and outcomes that
make the most difference in the lives of
individuals and communities
• Define the delivery system and societal costs
that measure the value of enhanced quality
• Build a framework for measurement that
rewards the quality of primary care through
relational networks
Rutherford, P., RN, Vice President, IHI; Coleman, E., MD,
Director, Care Transitions Program, University
of Colorado Anchutz Medical Center; Nielsen, G.,
Faculty, IHI
Reiss-Brennan, B., Mental Health Integration Director,
Intermountain Healthcare; Laderman, M., Research
Associate, IHI; Boudreau, K., MD, Chief Medical
Officer, Boston Medical Center HealthNet Plan
This Minicourse will address all the components
of excellent, efficient services for the last years
of a long life, which can be marked by multiple
chronic conditions, progressive disability, high
costs, and fragile balance with the environment.
Participants will learn how to identify and enroll
frail persons, adapt services to match their needs,
develop and optimize individual care plans,
integrate social services and health care, and
monitor and manage the local care system. This
session will include demonstrations, resources,
toolkits, production system redesign, advocacy,
and practical examples.
M16: Engage Physicians to Transform Care
Crystal Ballroom, Salon J
Improvement cannot be embedded into an
organization’s culture without the active
engagement of physicians. In this Minicourse,
we will describe a comprehensive model for
successful physician engagement, including the
role of a new physician-organization compact,
and explain how participants’ organizations
could adopt it. Presenters will also share relevant
perspectives from the ongoing efforts at Virginia
Mason Medical Center (VMMC) to improve care
and efficiency through implementation of the
Virginia Mason Production System, illuminating
the critical role of physicians in this work.
After this session, participants will be able to:
• Describe how urgency, shared vision, change
sponsorship, a compact (reciprocal expectations between doctors and their organization),
and a comprehensive method facilitate
physician engagement in improvement efforts
• Address the loss of autonomy that often blocks
physician engagement
From 2009 until 2013, IHI led a groundbreaking,
multi-state, multi-stakeholder initiative: STate
Action on Avoidable Rehospitalizations
(STAAR). The aim was to dramatically reduce
rehospitalization rates in states and regions by
supporting quality improvement efforts at the
front lines of care while simultaneously working
in parallel with state leaders to initiate systemic
reforms to overcome barriers to improvement.
This Minicourse will highlight the STAAR
Initiative’s progress to date in Massachusetts,
Michigan, and Washington.
After this session, participants will be able to:
• Describe the STAAR Initiative’s two concurrent
strategies to reduce avoidable rehospitalizations
• Identify common problems that contribute
to rehospitalizations as well as promising
approaches to reducing them
• Compare and contrast case studies from
sites that have implemented improvements
to dramatically reduce avoidable rehospitalizations
M18: Living Well While Old
and Frail — at Lower Cost
Key Biscayne
After this session, participants will be able to:
• Test the best tools and strategies for identifying
and serving frail elders
• Construct monitors of quality and cost
relevant to this population
• Test the business models and policy
changes that enable improvement while
also applying insights to building a plan
for their home community
Lynn, J., MD, Director, Center for Elder Care and
Advanced Illness, Altarum Institute; Deremo, D., RN,
President and CEO, Hospice of Michigan;
Brummel-Smith, K., MD, Chair, Department of
Geriatrics, Florida State University College of Medicine
25th Annual National Forum on Quality Improvement in Health Care
M19: Moving from Health Care
to Population Health
Harbor Beach
Inspired by dramatic improvements in Scottish
patient safety, the Scottish government has
launched the Early Years Program with the aim of
improving developmental outcomes for children
under age five. Engaging the civil sector, private
businesses, and charity organizations, this
program in population health improvement targets
education, early identification in general practices,
and community rehabilitation. This session will
explore the lessons learned when practitioners
make the leap from focusing on improving health
care to improving population health.
After this session, participants will be able to:
• Identify the key elements of a program that
aims to improve population health and
well-being in a population
• Work with others to develop improvement
plans for their organization
• Develop innovative ideas about moving
improvement techniques beyond health care
Leitch, J., Clinical Director, Quality Unit, Scottish
Government Health Department; Bennett, B., Principal
Advisor, Improvement Science Consulting; Gray, R.,
Head of Safety in Healthcare, Scottish Government;
Bell, D., Early Years Unit Head, Scottish Government;
Laing, S., Deputy Director, Early Years Project,
Scottish Government; Lewis, N., Director, IHI
Person- and
Family-Centered Care
M20: Beyond the Patient-Centered
Medical Home: Southcentral
Foundation’s Nuka System of Care
Grand Ballroom Salon 4-6
Southcentral Foundation (SCF) has been an NCQA
patient-centered medical home, Level 3 (highest
level), since 2010 and was awarded the Malcolm
Baldrige National Quality Award in 2011. Find
out why many medical systems nationally and
internationally are now looking to the SCF Nuka
System of Care as a way to transform a whole
system of care. With a foundation built on the
transfer of control and power to the patient,
long-term personal relationships backed by full
and open access, integration of the mind and
body, and a commitment to measurement
and quality, the Nuka System has resulted
in sustained, dramatic, and documented
improvements over 15 years. Utilization of
emergency departments and specialty care
has dropped in half, hospital days have dropped
by over 40 percent, and health outcomes as
well as customer and staff satisfaction have
dramatically improved. This Minicourse will
describe how SCF is moving beyond the concept
of the patient-centered medical home and will
present the continuing story of whole
system transformation.
After this session, participants will be able to:
• Review the transformational journey of an entire
health care system from physician-centered to
patient-centered to customer-owned
• Describe the systematic approaches to creating
and sustaining ongoing relationships between
a patient and physician that go beyond access
and communication
• Identify what is required to move beyond
a patient-centered medical home to a
customer-owned health care system
Gottlieb, K., President and CEO, Southcentral
Foundation; Eby, D., MD, Vice President of Medical
Services, Southcentral Foundation
Patient Safety
M21: A Sociotechnical Framework
for Driving a Culture of Safety, Clinical
Excellence, Continual Learning,
and Improvement
Vinoy
The pursuit of excellence in health care requires
a systematic framework that supports effective
assessment, intervention, measurement, and
sustainable improvement. The areas of patientand family-centered care, leadership, safety
culture, teamwork, reliable process, and systems
of learning must all be addressed to achieve
sustainable improvement. This Minicourse
will provide participants with a framework that
can be applied at a clinical-unit or service-line
level, whether in a hospital or a large health
system. Faculty will also offer practical tools
and techniques as well as examples of effective
application that participants can apply to their
own organization.
After this session, participants will be able to:
• Describe the components of a
framework for operational excellence
• Articulate to clinical and administrative leaders
their responsibilities as leaders of teams and
overseers of learning and improvement
• Make the link between clinical outcomes and
culture—including cultural measurement—
and discuss how to use measurement to
effect change
Frankel, A., MD, Principal, Pascal Metrics Inc.;
Leonard, M., MD, Principal, Safe & Reliable Care, LLC
and Adjunct Professor of Medicine, Duke University
School of Medicine
M22: Are You Ready for the Call?
Serious Event Response M
New York/New Orleans
Something terrible has just happened in your
organization. Perhaps a medication error has
caused the death of a patient, or numerous
patients have been exposed to contaminated
equipment. Are you prepared for such a serious
event? This interactive, case-based session will be
led by faculty with a wide range of experience in
administration, patient safety, risk management,
the legal issues involved in serious events, and
advocacy for patients and caregivers. Participants
will be able to develop a comprehensive response
plan, including caring for the first and second
victims of serious events.
After this session, participants will be able to:
• Assess their organization’s level of preparedness
to handle a serious event
• Develop an effective and comprehensive crisis
management plan that ensures respectful
treatment of patients as well as families
and caregivers
Stewart, K., Clinical Director, Clinical Effectiveness
Unit, Royal College of Physicians; Sadler, B., JD,
Senior Fellow, IHI; Deen, J., RN, JD, Patient Safety
Officer, Catholic Healthcare Partners; Kenney, L.,
President and Founder, Medically Induced Trauma
Support Services
M23: Protecting Children from Harm P
Aruba/Bahamas
Pediatric patient safety, a developing field in
health care, presents different challenges from
those found in adult-focused settings. Fortunately,
there is a growing knowledge base on which to
base interventions. Understanding the barriers
to the provision of safe care for children is key.
In this session, leaders from Pediatric International
Patient Safety and Quality Community (PIPSQC)
will present the latest theories on safety in child
services, from the community to the hospital,
focusing on child- and family-centered care.
After this session, participants will be able to:
• Identify the risks facing children in health care
• Develop a framework for pediatric patient
safety and access tools that can be used
in safety programs
• Utilize novel ways to protect children,
led by parents and caregivers
Lachman, P., MD, Associate Medical Director and
Consultant in Service Redesign and Transformation,
Great Ormond Street Hospital for Children NHS Trust;
Micalizzi, D., Pediatric Advocate, Advisor, and Educator,
The Task Force for Child Survival and Development;
Scanlon, M., MD, Knowledge and Solutions Architect,
Medical College of Wisconsin; Taitz, J., MB ChB, Director
of Medical Services, Royal North Shore Hospital
M24: Rethinking Critical Care:
Getting in Action M
Key Largo
Many patients in intensive care units require
sedation, mechanical ventilation, and other
life-saving interventions that can lead to
complications. Oversedation, immobility, and
delirium are a triple threat—separate yet
reinforcing complications that can lead to
long-term patient harm. Drawing from IHI’s
popular two-day seminar with our world-class
faculty, this session will help participants take
action to reduce sedation, increase delirium
detection, and improve mobility for critically
ill patients.
After this session, participants will be able to:
• Explain methods to monitor for delirium,
agitation, confusion, and sleep using the
Confusion Assessment Method for the ICU
(CAM-ICU) and the ABCDE (awakening,
breathing, coordination and choice of sedation,
delirium, and early mobility/exercise) technique
• Identify new techniques to reliably enhance
patient mobility earlier in the care process
McCutcheon Adams, K., LICSW, Director, IHI; Ely, E., MD,
Physician Scientist, Intensivist, Vanderbilt University;
Spuhler, V., RN, Nurse Manager, Intermountain Medical
Center; Clemmer, T., MD, Director, Critical Care
Medicine, LDS Hospital
19
Monday
SPECIAL EVENTS
Lean Health Care: John Kim and Associates (JKA) Vendor Presentation
4:45 PM – 5:15 PM
Palms Foyer Classroom
Lean Health Care: Hospitals, Physician Practices, and Health Plans
After 15+ years implementing Lean, JKA has emerged an industry leader in the integration of Lean principles and development
of supporting management systems in health care. Respecting differences in culture, objectives, and process has been the
key to customized approaches to improve access, satisfaction, quality/safety, and financial performance in physician practices,
hospitals, health system and health plans. Attend this session to learn more about JKA and how we can help you.
Welcome Reception
3:30 PM – 6:30 PM
Palms Ballroom, Exhibit Hall
IHI Fellowships Q&A Session
4:15 PM – 5:00 PM
IHI Booth #301, Exhibit Hall
Join current and past IHI fellows for an informal Q&A session about their IHI fellowship experience.
6th Annual IHI Open School Chapter Congress S
(sponsored by Kaiser Permanente)
4:30 PM – 7:30 PM
G Gaylord Palms, Sun Ballroom C
The IHI Breakthrough Series College Q&A Session
5:15 PM – 6:00 PM
IHI Booth #301, Exhibit Hall
Come and talk with the IHI Breakthrough Series College faculty about the design and content of the Breakthrough
Series College. We will share with you what makes for a great Collaborative topic and the kind of set-up you need
if you are considering running a Collaborative.
Faculty and Student Reception S
7:00 PM – 9:00 PM
G Gaylord Palms Emerald Bay Plaza
This networking event is offered specifically for IHI faculty, National Forum presenters, and health professions students.
20
25th Annual National Forum on Quality Improvement in Health Care
CONFERENCE DAY 1
Rapid Fire Workshops
10 minutes, 10 slides
Grand Ballroom, Salon 4-6
Tuesday
DECEMBER 10
keynote one
8:00 AM – 9:00 AM
In these fast-paced sessions, presenters will have
10 minutes to present 10 slides on the topics
listed below.
RFA: Lessons Learned from
Spread and Large Scale
Change Initiatives
Moderator: Schall, M., Senior Director, IHI
Presenters: Schilling, L., RN, National Vice President,
Healthcare Performance Improvement, Kaiser
Permanente; Davies, M., National Director, VHA
Systems Redesign, Veterans Health Administration;
McCannon, J., Faculty, IHI
special interest
keynotes
A1: Removing Waste from Health
Care: Lessons from the Choosing
Wisely Campaign and the Right
Care Alliance
9:30 AM – 10:45 AM
Cypress Ballroom 3
Cypress Ballroom 3
RFB: Health Systems as Employers
Grand Ballroom, Salon 4-6
Maureen Bisognano
President and CEO, IHI
Moderator: Coye, M., Chief Innovation Officer, UCLA
Health System
Presenters: Wozney, B., MD, Medical Director for
Ambulatory Quality and Informatics, Bellin Health
System; Bernard, P., CEO, Bon Secours Health System;
Skootsky, S., MD, Chief Medical Officer, University of
California Los Angeles Health Care
Storyboard Walkarounds
National Forum
Orientation
7:00 AM – 8:00 AM
Crystal Ballroom, Salon G
If you are new to the National Forum, we
suggest that you attend one of the National
Forum orientation sessions to help you
navigate through the program and devise
a personal learning plan. Participation in
National Forum orientation is free.
Cypress Ballroom 1
Daniel Wolfson, Executive Vice
President & COO, ABIM Foundation
Shannon Brownlee, Senior Fellow,
Lown Institute
Vikas Saini, President and CEO,
Lown Institute
B1: Global Lessons in Improvement
from Around the World
11:15 AM – 12:30 PM
Cypress Ballroom 3
NEW! Take a walking tour of some of the
exceptional storyboards submitted this year.
Each session will include a moderator and
storyboard presenters will stand beside their
boards to answer questions.
SWA: Identifying and Combatting Sepsis
Moderator: Grandhi, R., Student, University of
Cincinnati College of Medicine
Presenters: : Vovan, A., MD, Director of Clinical
Care, Hoag Memorial Hospital Presbyterian;
Barnes-Daly, M., RN, Regional Clinical Initiative
Lead, Sutter Health; Grbavac, B., RN, Regional
Supervisor, Performance Improvement, Franciscan
Alliance; Stromoski, D., RN, Sepsis Coordinator,
UPMC Shadyside
SWB: Patient Safety Initiatives
Moderator: Lichkus, J., Student, Boston University
School of Medicine and Harvard School of Public
Health
Presenters: Bock, K., MD, Director, Clinical
Information Systems, North Shore-LIJ;
Brockmeyer, D., MD, Medical Director,
Anticoagulation Service, Beth Israel
Deaconess Medical Center; Allen-Dicker, J., MD,
Physician, Mount Sinai Medical Center; Smith, P., MD,
Chief Medical Officer, Tenet Healthcare Corporation
Nigel Crisp, Former Permanent Secretary in
Health, United Kingdom and Former Chief
Executive, National Health Service England
Moderating a panel including:
Göran Henriks, Chief Executive of Learning
and Innovation, The County Council
of Jönköping
Wim Schellekens, MD, Strategic Advisor,
The Hague Area, The Netherlands
Jason Leitch, Clinical Director, Quality Unit,
Scottish Government Health Department
Haidee Davis, General Manager, Ko Awatea,
Counties Manukau District Health Board
Sodzi Sodzi Tettey, MD, Executive Director,
Department of Health, National Catholic
Secretariat, Ghana
Mike Richmond, Chief of Clinical Affairs,
Hamad Medical Corporation, Qatar
21
CONFERENCE DAY 1
A3/B3: Clinical and Cost Improvement
for Population Health
Crystal Ballroom, Salon D
Tuesday
DECEMBER 10
A workshops
9:30 AM – 10:45 AM
B workshops
11:15 AM – 12:30 PM
All A workshops repeat
during B workshops except
for special interest keynotes.
When clinical decision support is integrated
into health care information technology systems,
both cost and quality outcomes can be improved.
Under the health care reform law, evidence-based
health care is considered an important strategy
for developing accountable care organizations
(ACOs) and patient-centered medical homes
(PCMHs). In this workshop, we will discuss how
clinical decision support can help organizations
improve the cost and quality of care and build
the clinical infrastructure for ACOs and PCMHs.
After this session, participants will be able to:
• Identify the potential of evidence-based clinical
decision support for improving cost and quality
outcomes across the continuum of care
• Describe the potential role of clinical decision
support in the creation of ACOs and PCMHs
Weingarten, S., MD, Senior Vice President and Chief
Clinical Transformation Officer, Cedars-Sinai Medical
Center; Classen, D., MD, Associate Professor of
Medicine, Senior Partner and Chief Medical Officer,
Pascal Metrics, Inc.
A4/B4: Deliver Value with Volume
and Operating Room Efficiencies
Harbor Beach
A/B workshops
Quality, Cost, and Value
A2/B2: A Year in the Life: Living
with Long-Term Care
Grand Cayman/Puerto Rico
The “Year in the Life” program for patients with
chronic obstructive pulmonary disease (COPD)
provides a methodology to increase value in the
care provided to long-term-care patients at scale.
Using an educational approach and linking it
to improvement cycles and better information
systems, we saw higher quality at lower system
cost over one year in a population of COPD
patients across 188 general practices in four
boroughs. This workshop will discuss the key to
that success: Empowering patients by increasing
uptake of self-management plans and using a
care navigation tool.
After this session, participants will be able to:
• Use technology to identify service inefficiencies
• Develop, implement, and track
service improvements
Roberts, C., MD, Consultant, Barts and the London
NHS Trust; Meaker, R., Director of Innovation,
Redbridge CCG
In the current health care environment,
providers must quickly develop new models
of care delivery that increase both volume
and value. We can create value by delivering
exceptional care experiences as well as outcomes
through a patient-focused care center (PFCC),
which we build by co-designing the care
experience with patients, families, and providers.
In this workshop, we discuss how to manage
and focus all required resources, develop
high-performance care teams, and design
treatment through a full cycle of care.
After this session, participants will be able to:
• Deliver both value and volume to build
their own PFCC
• Improve clinical and operational outcomes
(including operating room efficiencies) while
decreasing waste and cost by focusing on
the experience rather than the service line
DiGioia, A., MD, Medical Director and Surgeon,
PFCC Innovation Center, University of Pittsburgh
Medical Center
A5/B5: Fast-Track Surgical Recovery
Crystal Ballroom, Salon P-Q
Participants in this workshop will learn how a
protocol to send postsurgical esophagectomy
patients to a telemetry floor with aid from MLPs,
rather than to the surgical intensive care unit,
resulted in a mean length of stay decrease of
seven days. Postsurgical complications also
showed a significant improvement. The cost
savings will be compared for the pre- and
post-intervention time frames.
After this session, participants will be able to:
• Illustrate the potential for cost savings
22
through improved postsurgical protocols
• Classify the savings potential for the eligible
and ineligible costs incurred in improving
patient outcomes
Schaub, D., Senior Statistical Applications Analyst,
University of Texas MD Anderson Cancer Center;
Shewale, J., Graduate Research Associate, University
of Texas MD Anderson Cancer Center
A6/B6: Improving Quality and
Reducing Costs: QUEST Year Five M
Grand Ballroom, Salon 3
During this session, participants will learn how
more than 330 hospitals participating in the
collaborative methodology of the QUEST initiative
have improved quality—in terms of evidencebased care, mortality, safety, readmissions, and
patient experience—while safely reducing costs.
These hospitals have avoided more than 30,000
acute care deaths while reducing costs by more
than $7 billion.
After this session, participants will be able to:
• Describe the six areas of focus of the
QUEST initiative
• Identify five tactics implemented by
high-performing QUEST hospitals to
achieve top performance
• Explain the value of transparent measurement
and QUEST’s collaborative methodology
in driving improvement across the
participating hospitals
Scott, C., RN, Service Line Vice President, Quality
and Safety, Premier, Inc.; Parsons, T., Vice President,
Tennessee Hospital Association
A7/B7: Nurse-Sensitive Measures
and Value-Based Purchasing F
Grand Ballroom, Salon 12-14
The success of hospitals’ pursuit of safe,
effective, efficient, timely, and patient-centered
care depends in part on their ability to engage
and use nursing resources effectively. In this
workshop, we will discuss this effort at North
Shore-LIJ, where structures and processes were
adapted to empower registered nurses with a
well-coordinated, multidisciplinary team approach
to patient care delivery. Excellent outcomes
were achieved, as reflected in nurse-sensitive
indicators that surpassed the national benchmark. The successful implementation of a
bundle of cost-effective, evidence-based practices
resulted in enhanced safety and quality outcomes
at North Shore-LIJ and increased revenues
through avoidance of $43 million in costs.
After this session, participants will be able to:
• Utilize structures and processes to enhance
patient experience, safety, and quality while
bending the cost curve
• Implement cost-effective, evidence-based
practices to achieve excellent outcomes in
nurse-sensitive indicators
Scanlon, K., RN, Chief Nursing Officer, North Shore
University Hospital, Deputy Chief Nurse Executive,
North Shore-LIJ; Memoracion, E., Director, Patient
Care Services, Long Island Jewish Medical Center;
White, M., Senior Vice President and Chief Nurse
Executive, North Shore-LIJ
25th Annual National Forum on Quality Improvement in Health Care
A8/B8: Leading the Way to Better
Care: Florida’s Quality Journey
A10/B10: Personal Mastery for
Transformational Leadership S
Sawgrass
Crystal Ballroom, Salon H
Five years ago, Florida’s hospitals set out to
improve care across the state. Working together,
they developed first-of-a-kind initiatives to reduce
readmissions, improve surgical outcomes, and
prevent infections. Today these efforts have
resulted in significant improvement and cost
savings: 11.2 percent reduction in readmissions,
10.5 percent reduction in complications, 38
percent drop in surgical site infections, 41 percent
drop in CLABSI, 37 percent reduction in CAUTI,
and at least $27 million in savings. Participants
in this workshop will learn how Florida’s hospitals
collaborated, innovated, and built a statewide
culture of quality.
Transformational change depends on how
fast and how far people shift their habits, role
patterns, and ways of thinking and relating.
Emotional tension and resistance are human
and ubiquitous constraints. Within such stress
and complexity, leaders are faced with the
difficult task of simultaneously managing their
own reactions, standing firm on decisions, and
engaging others with individual consideration.
In this workshop, faculty will present methods
to enhance “personal mastery”—learning the
way to desired results and creative relationships.
After this session, participants will be able to:
• Describe how Florida’s hospitals worked
together to significantly improve care while
reducing costs across the state
• Identify the key lessons learned over the
five years Florida’s hospitals worked together
on nation-leading programs to reduce
readmissions, complications, and infections
• Develop actionable steps for collaboration
around quality improvement in their own state
Greene, H., President and CEO, Baptist Health
Improvement Capability
A9/B9: Getting by with a Little Help
from… Students? S
Grand Ballroom, Salon 9-10
More and more, students are joining quality
improvement efforts in their local health care
settings. Future nurses, physicians, and
administrators are looking at processes and data
with fresh ideas. Are they helping? Or are they
just another hand to hold? In an innovative,
debate-style workshop, listen to both sides
of the argument as professionals reveal their
experiences working with students from
different health care disciplines. Join in the
spirited arguments—which will be moderated
by the IHI Open School advisors—and share
your feedback about working with the next
generation. Have you been inspired? Frustrated?
In this workshop, participants’ input can help the
conversation as we define best practices that will
be actionable immediately after the conference.
After this session, participants will be able to:
• List at least two ways in which students
can be helpful in quality improvement efforts
in a health care setting
• Defend why it’s important for their
organization’s future to have students
involved in its quality improvement efforts
• Recognize an innovative way to present
information to an audience of health care
professionals and students
Madigosky, W., MD, Director, Foundations of Doctoring
Curriculum, University of Colorado Anchutz Medical
Center; Moses, J., MD, Director of Safety and Quality,
Department of Pediatrics, Boston Medical Center
After this session, participants will be able to:
• Explain how to identify and respond effectively
to reactions in oneself and others that may
interfere with progress
• Identify key elements for facilitating creativity
in order to change habits and patterns
• Define ways to exercise authority that also
help to preserve positive engagement
Baker, N., MD, Principal, Neil Baker Consulting
and Coaching
A11/B11: Please, No More Red,
Yellow, and Green M
Crystal Ballroom, Salon N
In all organizations, it’s vital that senior
leaders and board members are able to view
key measures of the organization’s status in ways
that further their ability to ask pivotal questions,
draw valid conclusions, and make insightful
decisions. Often senior leadership is presented
with data for system-level measures in a tabular
summary or other relatively flat ways, such as
color-coding, that are of limited utility for learning.
Participants in this workshop will learn the latest
in how to display measures for senior leaders
more powerfully and effectively.
After this session, participants will be able to:
• Identify why tabular or color-coded methods of
displaying key measures to senior leaders are
inadequate for learning and improvement
• Identify the key design elements of a great
vector of measures (VOM)
• Analyze a VOM
Murray, S., Improvement Advisor, CT Concepts;
Provost, L., Statistician, Associates in Process
Improvement; Penner, J., Executive Director,
Mecklenburg Emergency Medical Services Agency
A12/B12: Raising the Bar for
Health System Boards
Vinoy
Too often, health organization boards of directors
are “bit players” in the unfolding drama of health
care strategy and governance. Traditional board
roles, such as philanthropy, are no longer enough.
In this session, presenters will pool their extensive
experience in health care governance to describe
the characteristics of a high-performance board.
They will also discuss principal board roles, the
qualities of ideal directors, ways to partner with
management, and innovative board practices and
policies.
After this session, participants will be able to:
• Identify the strengths and weaknesses of their
board of directors’ approach to governance
• Implement board activities or practices
previously untried by their board
• Assess the degree to which their current
board members fit the organization’s needs
Berry, L., PhD, Distinguished Professor of Marketing,
Texas A&M University; Toussaint, J., MD, CEO,
ThedaCare Center for Healthcare Value
A13/B13: Spread and Network
Methodology: IHI’s Best Practices
Crystal Ballroom, Salon J
At IHI, our work on collaboratives, campaigns,
virtual courses, and sprints has taught us a lot
about what works (and what doesn’t) when
spreading content to a large audience. This
session will provide an overview of network
theories, suggested content sequencing
principles, and spread tools that can assist
content delivered in a structured and predictable
way, facilitate proactive and meaningful
communication and support, and maintain high
energy across many large initiatives.
After this session, participants will be able to:
• Identify several strategies to develop and
support a network
• Describe practical tools that can be used to
spread clinical elements throughout a network
• Articulate several key network theories
Duncan, K., RN, Faculty, IHI; DeBartolo, K., National
Field Manager, IHI; Gunther Murphy, C., Director, IHI
A14/B14: Nurse Billing: Spreading
Initiatives in the Region F
Anaheim
This workshop will give participants ways to think
about navigating the challenge of standardization
of work across multiple regional clinics separated
by many miles. Participants will learn to use the
Gundersen Quality Improvement Toolkit, including
basic quality improvement tools, through the
specific example of instituting i-STAT testing of
international normalized ratios (INRs) for chronic
anticoagulation across three physically disparate
clinics. Presenters will also address the hurdles
of implementing nurse-only visits and billing.
After this session, participants will be able to:
• Show proficiency in using basic quality
improvement tools
• Extrapolate their experience in standard
work into their own disparate departments
• Discuss options for the implementation of
nurse-only billing
Gerhard, C., MD, Family Physician and Medical
Director, Gundersen Health System; Krause, J.,
Chief Quality and Patient Safety Officer, Gundersen
Health System
What workshop are you enjoying? Tweet it using #IHI25Forum
23
CONFERENCE DAY 1
Tuesday
DECEMBER 10
keynote two
3:15 PM – 4:15 PM
Cypress Ballroom 3
Eric Weihenmayer
World-class blind adventurer
A15/B15: The Design, Development,
and Use of Surveys in Health
Care Settings
• Develop a checklist of questions for any
commercial vendor hired to gather survey
data in their organization
Lloyd, R., PhD, Executive Director, Performance
Improvement, IHI; Williams, D., PhD, Improvement
Advisor, TrueSimple Consulting; Luther, K., RN, Vice
President, IHI
A16/B16: What Can England Teach
Us About Changing Health Care?
Crystal Ballroom, Salon A-C
Often we gain the greatest insights about our own
health system by looking at other systems. In this
workshop, spend 90 minutes with the English
National Health Service (NHS), the biggest health
system in the world. The NHS is implementing
the most radical changes in its 65-year existence
to position itself to deliver high-quality care within
available resources. Participants will gain insights
into possibilities for change in their own system
by learning about the goals, methods, and
approaches to change at the NHS.
After this session, participants will be able to:
• Identify strategies to bring care closer to
patients’ homes, integrate care, and
transform the dynamics between
primary care and hospital care
• Discuss how to redesign care on a systematic
basis, building shared purpose, engaging
patients and employees, and aligning
incentives and pay for performance
• Take home approaches, tools, and insights
into transformation that they can apply in
their own setting
Bevan, H., PhD, Chief of Service Transformation, NHS
Improving Quality; Fairman, S., Director of Business,
Improvement and Research, Medical Directorate,
NHS England
Marco Island
Historically, health care providers have used
surveys to gather data that they have used
primarily for marketing or publicity purposes.
Over the past 10 years, however, there has
been a dramatic shift in the objectives of survey
research in health care settings. Today surveys
are used less for marketing and more for
demonstrating that the health care provider is
listening to the voice of the customer. Most
individuals developing surveys in health care
organizations, however, have little or no formal
training in survey design and methods, and the
surveys they create are often poorly worded,
use the wrong response scales, achieve a
low response rate, and/or are analyzed and
interpreted incorrectly. Management is left
wondering why survey results don’t confirm
their views of reality. This workshop will help
participants turn this process around by
presenting the critical elements of a
well-designed survey that they can use
in their organization.
After this session, participants will be able to:
• Describe the key steps in designing,
implementing, and using surveys in
health care settings
• Design a roadmap for developing their
own ad hoc surveys
24
Triple Aim for Populations
A17/B17: An Innovative Approach
to Delirium Management
Crystal Ballroom, Salon E-F
Hospitalized patients older than 65 who develop
delirium have a 40 percent mortality rate over
12 months. One Kaiser Permanente facility
responded to this challenge of improving outcomes for this population by applying existing
industry best practices for the management of
delirium. Through more effective use of relevant
protocols, orders sets and medications, and
comprehensive staff education, the patient care
experience at this facility was improved. This
workshop will outline the ways in which the
Kaiser Permanente program resulted in a
23 percent reduction in average length of
stay for patients with delirium.
After this session, participants will be able to:
• Describe the serious effects of delirium on the
fragile, elderly population (morbidity, mortality,
and increased length of stay)
• Recognize the positive effect of a multidisciplinary, team-based approach to delirium care
on the management of this disease process
• Identify ways to begin implementation of a
delirium management program
Angel, C., MD, Kaiser Foundation Hospital; Brooks, K.,
MD, Psychiatrist, Kaiser Permanente Medical Group
A18/B18: Psychiatric Emergency
Department Patients: Special
Handling Needed
Chicago/Denver
Although it is estimated that up to 25 percent
of emergency department (ED) visits have a
behavioral health component, this area of
emergency care and operations is not as well
developed as others. This workshop will
discuss ways to address the special needs of
the psychiatric patient by deploying an operations
management approach: Training staff to “see
through the patient’s eyes,” linking to community
resources, and tracking improvements.
Participants will learn how to use this approach
to enhance overall flow and improve the patient
and ED staff experience.
After this session, participants will be able to:
• Describe the challenges of serving behavioral
health patients and discuss countermeasures
• Identify the opportunities to improve the flow
of behavioral health patients and enhance
services to this population
Nolan, K., Statistician, Associates in Process
Improvement; Jensen, K., MD, Chief Medical
Officer, BestPractices, Inc.; Crane, J., MD,
Emergency Medicine Faculty, IHI
A19/B19: Staying Alive: Computers
to Keep Elderly Active
St. Thomas/West Indies
This presentation will describe Wisconsin’s
community-based research—funded as an
Agency for Healthcare Research & Quality
(AHRQ) Center of Excellence in Active Aging
Research—in 23 counties. This research used
computer technology to help elderly (and family
caregivers) reduce falls, scams, loneliness, and
isolation, as well as improve driving safety and
medication management. Faculty will present
demonstrations of technology as well as a
community organization approach they have
used to build community engagement, including
evaluation plans and pilot test results.
After this session, participants will be able to:
• Describe how to integrate several technologies
to reduce the risk of an elderly person having
to enter assisted living or a nursing home
• Detail one approach to using community
organization strategies to implement a
Triple Aim project in multiple counties
Gustafson, D., PhD, Director, Center for Health
Enhancement Systems Studies, University
of Wisconsin
25th Annual National Forum on Quality Improvement in Health Care
A20/B20: Triple Aim Strategies for
High-Risk, High-Cost Populations
Grand Ballroom, Salon 7
Patients with complex needs often have difficulty
getting the exact services they need and end
up using expensive—but avoidable—services,
including emergency department visits and
hospitalizations. Health care organizations
moving to models of cost accountability need
robust strategies for serving the small percentage
of patients who account for the majority of health
care spending. Participants in this workshop
will learn to apply IHI Triple Aim change ideas and
measurement strategies to get better results
for their high-risk, high-cost patients.
After this session, participants will be able to:
• Apply segmentation strategies to the
identification of high-risk, high-cost patients
• Develop action plans to better understand
the needs of these patients from a
person-centered viewpoint
• Use “change concepts” that can be applied
to this patient population to design the first
set of tests to be implemented in a care
redesign process
Ramsay, R., Director of Community Care, CareOregon;
Brooks, K., Project Manager, Triple Aim Initiatives, IHI
Person- and
Family-Centered Care
A21/B21: Always Events®—Always
as a Concept P
Crystal Ballroom, Salon K-M
Always Events (AEs) are evidence-based practices
that ensure patient and family engagement. In
this session, the guiding principles of AEs will
be shared, and participants will be challenged
to create an AE for their own setting.
After this session, participants will be able to:
• Describe the guiding principles of AEs
and how they contribute to patient- and
family-centered care
• Develop a proposed AE outline for their
own care setting
Hayward, M., Lead, Patient and Family Engagement,
IHI; Balik, B., RN, Senior Faculty, IHI, and Principal,
Common Fire Healthcare Consulting; Carter, R.,
Senior Vice President, Planetree
A22/B22: Heart Failure: Policy
and People P
Aruba/Bahamas
Robert is 49 years old with end-stage cardiac
failure. We have known him for 20 years but
only recently started to see the world and our
care through his eyes. In this interactive session,
participants will also meet Robert and experience
the care he has received through his eyes as he
tells his story. We will then tie Robert’s story to the
broader concept of reliable implementation of a
strategic priority—heart failure care in Scotland.
After this session, participants will be able to:
• Understand heart failure from the
patient’s perspective
• Describe key steps in the reliable delivery
of care to heart failure patients at both the
micro and macro levels
Labinjoh, C., MB ChB, Consultant, NHS Forth Valley;
Mondoa, C., Consultant Nurse–Cardiology, NHS Forth
Valley; Longmate, A., MB ChB, National Clinical Lead
for Patient Safety, Scottish Government
A23/B23: Why Some Doctors Don’t
Listen and What You Can Do About It
Crystal Ballroom, Salon G
Today’s health care is replete with “cookbook
medicine”: Doctors ordering tests rather than
listening to each patient’s story. Using real-life
narratives to illustrate the concepts, a physician, advocate, and author speaks about the
importance of the patient story and the critical
role it plays in getting to the right diagnosis and
preventing medical error. The presenter will offer
five practical suggestions to make sure the doctor
listens and will illustrate them with interactive
exercises to improve communication and
ensure engagement.
After this session, participants will be able to:
• Describe the problems with today’s “cookbook”
approach to medical care and how it
came about
• Discuss how important it is that the doctor or
other health care provider hear the patient’s
story to get to the right diagnosis
• Take steps to become empowered to get their
own doctor or health care provider to listen and
help them get the medical care they deserve
Wen, L., MD, Emergency Physician, Harvard
Medical School
A24/B24: A High-Quality Safe
Medicines System for Patients M
Grand Ballroom, Salon 1-2
Ten percent of hospital admissions result from
adverse drug events, while five percent of
inpatients suffer such a reaction. The result
is both increased length of stay and higher
readmission rates. By reengineering the
medicines system, health care providers can
enhance both quality and efficiency, with a
return of about $12 for every $1.50 invested.
This presentation will compare and contrast
an integrated medicines system in Northern
Ireland and a non-integrated medicines system
in the USA.
After this session, participants will be able to:
• Describe how an integrated medicines
management process can reduce harm
and costs for acute care patients
• Discuss how to establish such a system
in their organization
• Identify two ways in which patients can be
engaged in this process in their organization
A25/B25: Changing Practice:
The Process to Reduce Seclusion
Miami
Reducing the use of seclusion and restraint is a
critical issue for enhancing the safety of patients
in mental health programs. One of the core
strategies for reducing these unsafe practices is
workforce development. St. Joseph’s Healthcare
Hamilton undertook an evaluation project to
examine staff skills in de-escalation strategies
with patients, as a way to reduce the use of
seclusion. This interactive presentation will
include background on the developing science
of de-escalation, skills assessment, and a content
analysis of the simulations completed.
After this session, participants will be able to:
• Explain the science behind verbal
de-escalation strategies so as to apply
these lessons to their own setting
• Practice using both “good” and “bad”
de-escalation strategies in small groups
• Implement a method to improve staff skills in
the use of de-escalation strategies with patients
Bieling, P., Director, St. Joseph’s Healthcare Hamilton,
and Associate Professor, McMaster University;
Madsen, V., Manager, St. Joseph’s Healthcare
A26/B26: Goal Zero: South Carolina’s
Commitment to Safety
New York/New Orleans
The South Carolina Safe Care Commitment
(SCSCC) is a groundbreaking, ongoing initiative
of 20 South Carolina hospitals from seven
health systems, including academic medical
centers, community hospitals, and a VHA facility.
Participants will learn how the South Carolina
Hospital Association and the Joint Commission
Center for Transforming Healthcare partnered
to employ the Center’s High Reliability
Self-assessment Tool (HRST) and other
innovative methods and measurements,
resulting in strengthened systems, improved
safety cultures, and better patient outcomes.
After this session, participants will be able to:
• Explain the methodology applied by the
SCSCC to achieve dramatic reductions in
preventable harm
• Describe how the SCSCC helped shift hospital
cultures of safety and the methods it used
to embed these changes within and across
hospital systems
• Identify ways in which their organization can
apply the learnings, methods, and tools to
replicate the results and improvements
achieved by the SCSCC
Smith, C., RN, Black Belt, High Reliability Initiatives
Director, The Joint Commission; Kirby, T., JD, President
and CEO, South Carolina Hospital Association; Diller,
T., Vice President, Quality and Patient Safety, Greenville
Hospital System
Scott, M., PhD, Head of Pharmacy and Medicines
Management, Northern Health and Social Care Trust;
Federico, F., RPh, Executive Director, Strategic Partners,
IHI; Niemann, J., RPh, PharmD, Director of Pharmacy
Services, Mercy Health Southwest Ohio
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25
CONFERENCE DAY 1
Tuesday
DECEMBER 10
Storyboard Walkarounds
1:30 PM – 2:45 PM
Cypress Ballroom 1
NEW! Take a walking tour of some of the
exceptional storyboards submitted this year.
Each session will include a moderator and
storyboard presenters will stand beside their
boards to answer questions.
SWC: Engaging the Patient to Transform Care
Moderator: Bhaskarabhatla, S., Researcher,
Bhaskara Group Consultancy
Presenters: Showecker, G., Clinical Application
Coordinator, Chalmers P Wylie VA Ambulatory
Care Center; Osborne-Stafsnes, J., Patient
Engagement Program Manager, California
Center for Rural Policy; Radel, K., Operations
Director, Allina Health; Runcimen, E., RN,
London Health Sciences Centre
C workshops
1:30 PM – 2:45 PM
C workshops do not repeat.
special interest
keynote
C1: Fully Transparent
Medical Records: Prospects
and Problems
1:30 PM – 2:45 PM
Cypress Ballroom 3
Tom Delbanco, MD, Professor of
General Medicine and Primary Care,
Harvard Medical School and Beth
Israel Deaconess Medical Center,
and Co-Director, OpenNotes
Jan Walker, RN, Principal Associate in
Medicine, Harvard Medical School and
Beth Israel Deaconess Medical Center,
and Co-Director, OpenNotes
C workshops
Quality, Cost, and Value
C2: Co-Creating a Sustainable
Healthy Tomorrow F
Crystal Ballroom, Salon G
Minnesota is pioneering a model of “co-creation”
that fosters community conversations and actions
around the IHI Triple Aim by bringing together
clinicians, patients and citizens, and community
stakeholders. This multi-phased project will
support “accountable health communities” in
which local, clinical, citizen leaders review
their own data and set local goals and action
plans based on the IHI Triple Aim. Through local
leadership, community stakeholders address
the issues associated with improving health,
the experience of care, and the affordability of
health care.
After this session, participants will be able to:
• Identify the strategies employed within select
Minnesota communities to comprehensively
engage clinicians, citizens, and community
stakeholders seeking alignment around all
aspects of the IHI Triple Aim
• Detail the elements that are critical to success
in building an accountable health community
C3: Digital Health Technologies
for Lower Costs and High Value F
Crystal Ballroom, Salon K-M
Digital health technologies (DHTs), wisely applied, are transforming many industries—including some areas of health care where recent
innovations are causing rapid transformations
and impact. These developments may be just
the beginning, and this session will provide an
overview of what is coming. Presenters from
Scandinavia and the Veterans Health
Administration (VHA) will discuss promising
and proven DHTs; outline resources to help
with implementation; and use examples to
describe how to develop patient-centered care
and estimate costs and returns on investment.
After this session, participants will be able to:
•List the main DHTs that will have an impact
on their work, services, health systems, and
health plans and identify areas of industry
disruption from new DHT service combinations
•Identify innovations to promote patient-centered
care and co-service
•Apply lessons and methods for implementation
and cost and savings estimation to their
own organization
Ovretveit, J., PhD, Professor, Karolinska Institute
C4: The Improvement Opportunity
in Real-Time Location Systems F
Harbor Beach
This session describes Real-Time Location
Systems (RTLSs) and the progressive expansion
of their applications to improve health care quality
and patient safety, reduce health care costs, and
mitigate risk exposures. The most significant
improvement opportunities are associated with
applications that permit real-time tracking of
hospital staff, patients, and movable equipment
and that facilitate automation, monitoring, and
improvement of clinical work flows in the
emergency room, the operating room, and
other key hospital locations.
After this session, participants will be able to:
• Describe three RTLS applications that
address patient safety issues
• Provide two examples of data-based
improvement opportunities in a typical
emergency department
• Describe two ways in which RTLS
supports significant cost reductions
O’Leary, D., MD, President Emeritus, The Joint
Commission; Chow, M., PhD, RN, Vice President,
National Patient Care Services, Kaiser Permanente
Magnan, S., MD, PhD, President and CEO, Institute
for Clinical Systems Improvement (ICSI); Hanley, B.,
Vice President, Public Engagement, Twin Cities Public
Television; Kershaw, S., Executive Director,
Citizens League
26
25th Annual National Forum on Quality Improvement in Health Care
Improvement Capability
C5: Daily Huddles: Developing
Situational Awareness M
Crystal Ballroom, Salon N
In any health care organization, the status of
operations and ability to identify problems early
is critical to safety concerns. During this session,
experts will discuss how to implement and use
daily check-ins at different levels of the
organization to improve safety.
After this session, participants will be able to:
• Discuss how daily check-ins increase the
resilience of an organization
• List the steps necessary to implement daily
huddles in their organization
Federico, F., RPh, Executive Director, Strategic Partners,
IHI; Yates, G., MD, President, Sentara Quality Care
Network and Healthcare Performance Improvement,
LLC, Sentara Healthcare
C6: Engaging Front-Line Staff
in Real-Time Improvement S
Crystal Ballroom, Salon H
Traditional suggestion systems can be ineffective
in engaging staff and creating real impact. In this
session, participants will hear an organizational
case study on equipping front-line leaders with
a different approach. Grounded in Lean and
innovation principles, a staff idea system, and
standardized leadership routines—including
regular rounding and huddles—this approach
enables staff to chip away at the rampant waste
in health care. Presenters will describe design
elements, examples, and critical success factors.
After this session, participants will be able to:
• Discuss the difference between a suggestion
system and a Lean-influenced idea system
• Describe daily leadership routines that
engage staff in improvement
• Identify critical success elements when
implementing such an approach
Phillips, J., Director, Center for Innovation, Virginia
Mason Medical Center; Mann, S., RN, Director
of Nursing, Virginia Mason Medical Center
Patient Safety
C7: Physician Culture Is a
Solution, Not a Problem
Grand Ballroom, Salon 7
Physician leadership is central to superb
organizational culture and excellent outcomes.
However, top-notch physician leadership will
not spring from a disaffected, exhausted group
of physicians. Invest in physician careers with
a focus on selection, values, and leadership
development. Use neuroscience research and
courage (not off-the-shelf software) when
designing recognition and discipline programs.
Invite in the excellent, expel the toxic, and your
reputation, business results, and progress on
the IHI Triple Aim will improve.
After this session, participants will be able to:
• Identify the costs of physician disaffection
• Use neuroscience to guide physician
work-life interventions
• Identify three steps to repel toxic behavior
Fahy, P., MD, Consultant, Fahy Consulting
C8: Privacy vs. Visibility in a Radial
Nursing Unit
Anaheim
Quality health care begins long before patients
and staff interact. It begins on the drawing board,
where design decisions affect patient and staff
well-being and efficiency for years to come. This
workshop will present results from an investigation
of whether moving the orientation of patient beds
in a radial nursing unit affects patient satisfaction,
falls, HCAHPS scores, and nurse time spent in
patient rooms. Is the increased privacy for
patients worth the decrease in patient visibility
from the workstation?
After this session, participants will be able to:
• Identify the potential benefits and trade-offs of
specific design decisions, such as the locations
of patient headwalls and nursing station units
• Make use of the impact of design decisions on
a wide variety of factors, including patient
satisfaction, patient fall rates, acoustical
environments, emergency response times,
and patient outcomes
• Implement a model for evidence-based design
decision-making, using research to drive
specific design decisions
Bosch, S., PhD, Director of Research, Gresham, Smith
and Partners; Hiltonen, B., Senior Interior Designer,
Gresham, Smith and Partners; France, L., RN, Nurse
Manager, Florida Hospital Waterman; Worden-Kirouac,
E., Interior Designer, Gresham, Smith and Partners
C9: Reliability and Human Factors
Sciences: Employing Engineering
Concepts in the Development of
High-Reliability Health Care
Crystal Ballroom, Salon D
This course introduces participants to the utilization
of process reliability science and engineering
concepts to improve health care. Faculty will
provide examples from other industries where
process reliability stabilized structure and led to
reliable outcomes and high-performance culture.
In exploring process reliability within the use of
the IHI safety bundles, faculty will also illustrate a
tangible return on investment with respect to cost
and culture and introduce didactic and interactive
methods from human factors science for achieving
performance improvement.
After this session, participants will be able to:
• Explain the use of human factors science,
reliability science, and engineering principles
in performance improvement
• Describe examples from other industries of
reliability science, human factors science,
and engineering principles being used with
measurable success
• Build the business case for the use of these
concepts in health care, with the IHI safety
bundles as an example
Krueger, J., MD, Vice President, Medical Director of
Quality, UnityPoint Health; Troyer, D., President,
Troyer Reliability Consulting
C10: Stress and Its Impact on
Physicians and Their Families
Marco Island
Work-related stresses and job dissatisfaction are
rapidly growing for physicians. Focusing on the
magnitude of the problem and its root causes, this
workshop will describe the impact of stress and
dissatisfaction on physicians, on their spouses
and families, and on patient care and safety.
Faculty will share effective approaches and
describe the organizational programs available
to help participants recognize and address these
problems in their own organization.
After this session, participants will be able to:
• Recognize signs and symptoms of physician
stress in organizations and the impact on not
only their personal and professional lives but
also patient care and safety
• Identify successful programs and approaches
to managing physician stress that can be
implemented in their organization
Boehler, R., MD, President and CEO, St. Joseph Hospital
C11: The Invaluable Improvement
Advisor
Grand Ballroom, Salon 4-6
Many organizations seeking to build improvement
capacity have found the role of the Improvement
Advisor (IA) invaluable to their strategic success.
This presentation will discuss the IA role as a
leader focused on results and devoted to helping
identify, plan, and execute improvement projects
throughout the organization. In this session,
participants will learn the core skills necessary
for an IA and be given tools to help initiate an
improvement project. The presenters will
demonstrate practical applications of these
skills and tools through case stories.
After this session, participants will be able to:
• Identify the role and core skills of an IA
• Assess organizational capacity for leading,
planning, and executing improvement projects
Ray, D., IA Program Director, Strategic Communications
Consulting, LLC; Moen, R., Consultant, Associates in
Process Improvement; Posencheg, M., MD, Medical
Director, Intensive Care Nursery, University of
Pennsylvania Hospital
C12: Turning the World Upside Down
Sawgrass
Even without resources or vested interests,
developing countries are continuously innovating
and developing new improvement in health care.
This session will review successful examples of
innovative practices from developing countries
that have been used in developed-country
settings. Focusing on mental health settings,
this session will highlight examples and
commentary from around the world.
(continued on next page)
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27
CONFERENCE DAY 1
Tuesday
DECEMBER 10
After this session, participants will be able to:
• Review new mental health programs
and practices from developing countries
• Identify the principles that could be
applied to their area of health care
Crisp, N., Former Permanent Secretary in Health,
United Kingdom, and Former Chief Executive,
National Health Service England; Belkin, G.,
Associate Professor, NYU School of Medicine,
Senior Director for Psychiatry, New York City
Health and Hospitals Corporation
Improvement Capability
C13: Achieving IHI Triple Aim
Results for Working-Age Adults:
Better Health, Better Care, and
Lower Cost for Employed Populations
Vinoy
Bellin Health, a long-standing IHI Triple Aim
prototyping partner, has improved health scores
of its employees while reducing health costs and
saving over $17 million. Applying the lessons of
population health, Bellin has spread these strategies to hundreds of companies in Wisconsin and
Michigan, developing strategic partnerships with
employers and working towards results together.
After this session, participants will be able to:
• Explore the drivers of population health to
better understand the needs of
employed populations
• Employ an integrated approach to produce
results in each dimension of the IHI Triple Aim
• Draw lessons and strategies that can be
applied to their own organization
Van Straten, R., Vice President, Business Health, Bellin
Health; Kerwin, G., President and CEO, Bellin Health
C14: At Home: Comprehensive
Care of the Frail Elderly
Grand Ballroom, Salon 1-2
Advanced-illness programs that deliver care
at home to the frail elderly and other high-risk
populations can substantially improve outcomes.
One such program, delivered by North Shore–
LIJ Health System (North Shore–LIJ), provides
services to vulnerable and largely disenfranchised
patients. This session will discuss the success of
this program in substantially reducing hospital
visits and improving satisfaction. Participants will
also learn how the program has enabled a higher
28
percentage of patients to die at home, through
the use of an on-demand clinical model, real-time
analytics, community paramedicine, and tight
coordination with post–acute care services.
After this session, participants will be able to:
• Develop, both culturally and operationally,
an on-demand clinical model to respond
to changes in clinical status
• Use real-time analytics to coordinate
care and identify patients in need of
higher-intensity services
• Leverage community paramedicine to
assist with patient evaluation and triage
during off-hours
Jervis, R., MD, Director of Quality, Advanced Illness
Management Program, North Shore–LIJ; Poku, A.,
Clinical Data Analyst, North Shore–LIJ; Smith, K., MD,
Vice President and Medical Director for Advanced
Illness Management, North Shore–LIJ
C15: Breaking the Silent
Epidemic of Chronic Obstructive
Pulmonary Disease P
Crystal Ballroom, Salon E-F
Despite being the third-highest cause of both
death and hospital readmissions, chronic
obstructive pulmonary disease (COPD) is often
the silent epidemic in a community. This
workshop will tell the story of the Southern
Piedmont Beacon Community’s adventure
in breaking through the silence surrounding
COPD and hardwiring a community for improved
outcomes. Participants will hear from a patient—
national spokesperson Grace Ann Dorney
Koppel—as she shares her story and her
own commitment to breaking the silence of
the epidemic. Presenters will lead participants
through a journey they can re-create in their
communities—from screening to spirometry,
global initiative for chronic obstructive lung
disease (GOLD) guidelines, patient engagement,
and pulmonary rehabilitation.
After this session, participants will be able to:
• Identify the necessary elements of a
patient-centered disease management
program for COPD patients
• Develop a plan for leading change in their
community to break the silence of the
COPD epidemic
• Utilize geo-mapping tools to understand
their community’s burden of disease
Dorney Koppel, G., Private Practice Attorney and
Spokesperson, COPD; Wright, J., MD, Vice President,
Innovation, Carolinas Medical Center; Stearns, M.,
Director of Cardiopulmonary and Pulmonary Rehab
Services, Carolinas HealthCare System
C16: Measurement for Managing
Populations
Grand Ballroom, Salon 3
Many organizations and communities struggle
with Triple Aim measurement issues. In
this session, we will provide frameworks,
practical guidance, techniques, resources,
and case examples for measuring the IHI Triple
Aim. Focusing primarily on measurement of
population health, we will draw from our
experience at Kaiser Permanente and Health
Partners, as well as through the international
IHI Triple Aim community. This session will
be interactive to allow participants to share
successful practices and raise questions.
After this session, participants will be able to:
• Explain the measurement menu for
the IHI Triple Aim
• Describe other organizations that
have implemented IHI Triple Aim
measurement systems
• Apply techniques and successful
practices for measuring population health
Stiefel, M., Senior Director, CMI Center for Population
Health, Kaiser Permanente; Knudson, S., Vice
President, Health Informatics, HealthPartners
C17: Partnering for Improvement:
Promoting Child Health
Aruba/Bahamas
Underutilization of health resources, particularly
in underserved populations, places children
at significant risk. Home visiting programs
support maternal knowledge and mothers’
involvement in their children’s care. This
workshop will present results from a federallyfunded project to increase recruitment and
retention in home visiting programs in Georgia.
We will share the lessons learned from a
multi-site quality improvement project involving
diverse community-based organizations and
program graduates to enhance the engagement
of families in evidence-based programs that
promote child health.
After this session, participants will be able to:
• Explain the complexities of collaboration when
implementing a multi-site protocol to improve
engagement and retention rates of families in
programs to promote early childhood health
• Utilize strategies for partnering with local
providers to provide optimal health and
social services for clients and patients
Terris, D., Evaluation Unit Lead, Center for Family
Research, University of Georgia; Glisson, R.,
Evaluation Data Coordinator, Center for Family
Research, University of Georgia; Grange, C.,
Applied Research Scientist, University of Georgia
Person- and
Family-Centered Care
C18: Advancing Compassionate,
Patient-Centered Care
New York/New Orleans
Compassionate health care is the recognition and
validation of the needs, concerns, and distress of
others coupled with actions to offer amelioration
during every health-related interaction. Without
compassion, care cannot be patient-centered or
humane. Participants will engage in appreciative
inquiry to share experiences of compassionate
care, and they will identify the characteristics
of compassionate persons and systems as
well as barriers to compassion. Faculty will share
findings on these characteristics from a recent
national meeting involving 60 health care leaders.
25th Annual National Forum on Quality Improvement in Health Care
Participants will identify potential action steps to
advance the provision of compassionate health
care in their own organizations.
After this session, participants will be able to:
• Describe the impact of compassionate
health care on health care providers,
patients, and families
• Discuss what a compassionate health
care organization looks like
• Identify action steps to advance the
provision of compassionate health
care in their own organizations
Lown, B., MD, Medical Director, Schwartz Center
for Compassionate Healthcare; Crocker, L.,
Health Consultant and Writer, Institute for
Family-Centered Care
C19: Communication, Apology,
and Resolution After Error
Crystal Ballroom, Salon A-C
Despite best efforts, adverse events do occur
in health care settings. With the current liability
system, litigation is the main pathway for
harmed patients to seek compensation.
However, this approach not only interferes
with the relationship between patient and
caregiver and efforts to improve patient safety,
but also drives defensive medicine. Another
approach is communication, apology, and
resolution (CARe). This presentation will share
the experience of the Massachusetts Alliance
for Communication and Resolution Following
Medical Injury, implementing the CARe model.
After this session, participants will be able to:
• Describe the implementation in two health
systems of a disclosure, apology, and offer
program to respond to unanticipated
clinical outcomes
• Explain how to offer patients full disclosure,
honest explanations, and an apology with
rapid and fair compensation when standards
of care are not met
Benjamin, E., MD, Senior Vice President and Chief
Quality Officer, Baystate Health; Sands, K., MD,
Senior Vice President, Health Care Quality, Beth
Israel Deaconess Medical Center
C20: Is Your Health Care System
Conversation-Ready? F
Grand Cayman/Puerto Rico
The aim of The Conversation Project is to ensure
that individuals’ end-of-life wishes are expressed
and respected. To this end, our health care
system must be prepared to receive an activated
public and fully respect end-of-life wishes.
This session will outline what it means to be
“conversation ready” and present practical
strategies from individuals in the field working
to meet this ambitious aim.
After this session, participants will be able to:
• Define what it means to be conversation ready
• Identify practical strategies for becoming
conversation ready that can be applied in
their organization
C21: Patient-Centered Segmentation
and Designing for Health
Chicago/Denver
This workshop will present a patient-centered
way of segmenting and designing services for
a defined population. Participants will learn
segmentation of a defined population based
on peoples’ goals, aspirations, motivation, and
context. After learning to design care specific to
the needs and aspirations of patient segments,
participants will be able to reduce waste in their
organizations, as well as improve uptake of
services and build patient engagement in care.
This methodology will give participants a deeper
understanding of their patient population.
After this session, participants will be able to:
• Explain the segmentation of a population
based on peoples’ needs and aspirations
• Describe the concept of persona used in
social marketing for segmenting the population
• Apply this approach through real examples
Whittington, J., MD, Lead Faculty, Triple Aim Initiative,
IHI; Vyas, D., Consultant Anesthetist, Calderdale and
Huddersfield NHS Trust
C22: Learning from Mid Staffs and
the Francis Inquiry: How Leaders Can
Detect Problems at an Early Stage
Grand Ballroom, Salon 12-14
In the past decade, quality of care and patient
safety in British hospitals have become the focus
of increasing public, professional, political,
and regulatory concern. In March 2008, the
Healthcare Commission announced that it
would investigate quality of care at the Mid Staffs
Foundation Trust, and its report in March 2009
documented appalling care at the Trust. This was
confirmed by a public inquiry, chaired by Robert
Francis, QC, that reported in February 2013. Yet,
many warning signs were present —the Trust had
a high adjusted death rate, had received several
mortality alerts, and had been warned by patients
of poor care in 2007. In January 2008, the IHI
report commissioned by the English Department
of Health, “Achieving the Vision of Excellence
in Quality: Recommendations for the English
NHS System of Quality Improvement” had made
recommendations for improvement in English
hospitals, and in 2013 Don Berwick reiterated
many of those recommendations in a report to
the Prime Minister, David Cameron. In this
session, faculty will trace some of the origins of
the problems at Mid Staffs, evaluate the advice
given by IHI, Francis, and Berwick, and indicate
how health care leaders can learn from the Mid
Staffs experience and pick up potential problems
at an early stage.
After this session, participants will be able to:
• Describe how the problems at Mid Staffs arose
• Identify the early signs of similar problems in
other health care systems
• Identify one way of developing early warning
systems from data analysis, patient and staff
feedback, and surveys
Jarman, B., PhD, Senior Fellow, Emeritus Professor,
Imperial College London; Selberg, J., Executive Vice
President and COO, IHI; Berwick, D., MD, President
Emeritus and Senior Fellow, IHI
C23: Combatting Surgical Site
Infections in Hip and Knee
Arthroplasty
Grand Ballroom, Salon 9-10
Three evidence-based practices have been
shown to reduce surgical site infections (SSIs)
following hip or knee arthroplasty: Screening
patients for Staphylococcus aureus carriage
and decolonizing carriers with nasal mupirocin;
bathing with chlorhexidine soap or wipes; and
using an alcohol-containing preoperative skin
disinfectant. Participants will benefit from the
work of Project JOINTS (Joining Organizations
IN Tackling SSIs), an IHI initiative, and learn
how to test and implement these interventions
in their facilities.
After this session, participants will be able to:
• Describe the rationale behind the three
evidence-based practices to reduce SSIs
• Define the elements of these practices
and identify ways to assess current
implementations of each practice
• Examine how other hospitals have
implemented these practices and identify
ways to apply them at their own facility
Duncan, K., RN, Faculty, IHI; Yokoe, D., MD, Hospital
Epidemiologist, Brigham and Women’s Hospital;
DiGioia, A., MD, Medical Director and Surgeon,
PFCC Innovation Center, University of Pittsburgh
Medical Center
C24: Creating New Care Models
to Ensure Patient Safety
Crystal Ballroom, Salon J
The program Partnership for Patients was
developed by the Center for Medicare and
Medicaid Innovation (CMMI) to further advances
in patient safety. Premier, a hospital engagement
network (HEN) of 450 hospitals in 37 states, will
share its approach in developing leadership and
culture, creating a reliability culture of failure
prevention, and integrating the human factor into
process design. Two Premier HEN hospitals will
share the low- and high-tech tactics they adopted
to achieve a sustainable 40 percent reduction in
the incidence of harm to patients.
After this session, participants will be able to:
• Identify tactics to reduce harm to patients
and sustain the reduction at their facility
• Develop a reliability culture of
failure prevention
Barrington, M., RPh, Vice President, Engagement
and Delivery, Premier, Inc.
McCutcheon Adams, K., LICSW, Director, IHI;
Gunther-Murphy, C., Director, IHI
What workshop are you enjoying? Tweet it using #IHI25Forum
29
C25: Crew Resource Management
Team Training: Improving Outcomes
in a Large Dutch Intensive Care Unit
C26: Hoshin Kanri for Patient Safety:
Success Stories F
St. Thomas/West Indies
The Cancer Institute at HRVP (State Regional
Hospital in Brazil) has developed a strategy
deployment for safety using leadership principles
that align daily management, safety “huddles,”
and alerts to its greater system measures. In a
similar vein, the Saskatchewan health care system
has made the adoption of a culture of safety its
strategic intent by using the Hoshin Kanri method.
Presenters will discuss these initiatives in Brazil
and Canada and present updates on the latest
developments.
In aviation, where human factors account for
the majority of adverse events, a form of human
factors awareness training called Crew Resource
Management (CRM) has had a significant impact
on air-crew team performance and flight safety.
Indeed, CRM has become the cockpit operational
standard in spite of a lack of scientific proof that
it works. In medicine, scientific evidence on the
effects of CRM is still scarce as well. In this
workshop, we will present findings from our
investigation of the effects of a CRM intervention
in an intensive care unit.
After this session, participants will be able to:
• Recognize the key role of human factors
in clinical team performance
• Implement the principles of CRM training
in their own organization
Schellekens, W., MD, Strategic Advisor, The Hague
Area, The Netherlands; Haerkens, M., MD, Surgeon
and Pilot, Wings of Care; Van der Hoeven, J., Professor
in Intensive Care Medicine, Radboud University
Nijmegen Medical Center
Miami
After this session, participants will be able to:
• Use both Hoshin Kanri to align organizational
goals and outcomes and the standard methods
for organizational alignment
• Describe the key attributes of a strategic
planning and deployment process that
embraces continuous improvement
principles and puts patients first
• Identify ways in which Hoshin Kanri planning
can be used to build a shared narrative and
facilitate health system transformation
Pinto, C., MD, Executive Director, Instituto de Oncologia
do Vale, Brazil; Peterson, K., Director, Health System
Planning and Policy, Government of Saskatchewan,
Ministry of Health, Canada
C27: The ACGME Clinical Learning
Environment Review (CLER):
Pathways to Excellence
Crystal Ballroom, Salon P-Q
This workshop will provide participants with
a brief overview of the CLER program, early
experience from the field, and an introduction
to the newly released document “CLER Pathways
to Excellence: Expectations for an Optimal Clinical
Learning Environment to Achieve Safe and
High-Quality Patient Care.” Through a series
of small group sessions, participants will have
the opportunity to explore the six focus areas
of patient safety, health care quality (including
reducing health care disparities), care transitions,
supervision, and duty hours/fatigue management to understand the relationship between
resident and fellow engagement. Participants will
also identify opportunities to optimize a learning
environment while improving patient care.
After this session, participants will be able to:
• Describe the rationale and goals of the
ACGME CLER program
• Identify characteristics of an optimal
clinical learning environment
• Identify opportunities to improve resident
engagement in institutional efforts to improve
patient safety and health care quality
Wagner, R., RN, Vice President, CLER Program,
Accreditation Council for Graduate Medical
Education (ACGME); Weiss, K., Senior Vice
President, Institutional Accreditation, ACGME
Visit the
IHI Open School Kiosk
Enroll in the IHI Open School online courses at the
National Forum and bring the spirit of IHI to your
home or organization! The Open School allows you
and your team to:
•
Take online courses that fit your schedule
• Earn up to 26 CE credits in a cost-effective way
• Connect with a like-minded community
•
Keep up with the latest in leadership and
quality improvement
Enroll now outside of Conference Information in the
Los Angeles room and enter to win a FREE registration to
the 2014 National Forum! The winner will be announced
at the final keynote session on Wednesday afternoon.
30
25th Annual National Forum on Quality Improvement in Health Care
Tuesday
SPECIAL EVENTS
Complimentary Yoga
6:00 AM – 7:00 AM
Key Largo
Kaiser Permanente: Imagining
Care Anywhere Vendor Presentation
PerfectServe Vendor Presentation:
How to Improve Outcomes and
Efficiency by Simplifying
Communication Processes so
Clinicians Can Better Coordinate Care
12:45 PM – 1:15 PM
Storyboard Reception
4:30 PM – 6:30 PM
Exhibit Hall
Representatives from organizations with
storyboards on display will be available to
answer questions, share lessons learned,
and network in an informal setting.
10:45 AM – 11:15 AM
Palms Foyer Classroom
Cypress 1
Effective communication among clinicians is
essential to reliable, high-quality care and efficient
care coordination. Yet current processes often
break down and create delays in treatment.
This session describes how PerfectServe works
with more than 30,000 physicians and 75
hospitals to remove variability and drive process
standardization, which results in improved
outcomes and operational efficiency.
Conversation Ready Q&A Session
DNV Vendor Presentation:
Putting Quality Back into
Accreditation: How ISO 9001
Drives Process Improvement
Open School Q&A Session
Presented by: Tyler D. Jones, Director, IT Strategic
Services, Kaiser Permanente
“Imagining Care Anywhere” demonstrates Kaiser
Permanente’s belief that IT is a critical driver in
reforming our nation’s health care system and
is leading the effort to make health information
technologies available at all points of care. This
segment provides a demonstration of how the
use of connected care, digital health, analytics
and big data, and other examples of technology
can be used to improve health outcomes. Join
the conversation about providing patients with
convenient, real-time, personalized care, and
transforming health care while improving wellness
and affordability with the use of technology.
Lunch and Learns
12:40 PM – 1:20 PM
Be The Change: Three Things
Needed to Achieve Health Equality
Crystal Ballroom, Salon H
Join a lively discussion about diversity and
health equity — one of the key issues in
health care today.
Social Media 101
Grand Ballroom, Salon 7
Curious about how to use Twitter and other
social media sites? Grab your lunch and join Paul
Levy, the social media-savvy former
hospital CEO, during this informal session.
IHI Work-Life Wellness Team
Q&A Session
10:45 AM – 11:15 AM
IHI booth #301, Exhibit Hall
IHI’s Work-Life Wellness team organizes activities
for IHI staff to encourage them to embrace and
live a healthy lifestyle. Meet members of the
team, discuss strategies for keeping your
employees well, and join in a fun fitness activity!
2:45 PM – 3:15 PM
Palms Foyer Classroom
The gradual Integration of ISO 9001 into
accreditation enables hospitals that have
been accredited by DNV Healthcare to utilize,
streamline, and improve their existing quality
system in a consistent and understandable
manner that fits each hospital uniquely. This
session presents practical dos and don’ts
gleaned from the integration experience of
hospitals nationwide.
DebMed Vendor Presentation:
Moving Beyond Direct Observation to
Electronic Hand Hygiene Monitoring
4:30 PM– 5:00 PM
Palms Foyer Classroom
View a short presentation on the DebMed® Group
Monitoring System, the only electronic hand
hygiene system now monitoring at the critical
point of patient care with monitored point-of-care
dispensers. Register to win a $500 Visa Gift Card!
4:15 PM – 5:00 PM
IHI Booth #301, Exhibit Hall
Join IHI staff to learn about a new program to
help communities and health care organizations
encourage and support conversations about
preferences for end-of-life care.
5:15 PM – 6:00 PM
IHI Booth #301, Exhibit Hall
Hear from IHI staff and Chapter Leaders and
learn more about the Open School for students
and professionals.
Sandlot Solutions Vendor Presentation:
Leveraging Community HIE to Achieve
the IHI Triple Aim
5:15 PM – 5:45 PM
Palms Foyer Classroom
Proactive patient-centered care coordination
relies on seamless, point-of-care access to
community-based health records derived from
interoperable health information exchange (HIE)
and analytic tools that close the gaps in care.
A large physician independent practice
association leveraged an HIE and analytics
platform to achieve lower utilization, cost
reductions, improved patient care, and
dramatic progress in population health quality.
25th National Forum Celebration
6:30 PM – 10:00 PM
Marriott Pool Pavilion
Join us by the pool to
celebrate 25 years of health
care improvement. We’ll be
providing food, drinks, and
entertainment. This event is
free of charge.
National Forum
31
SPECIAL interest
Breakfasts
Network with colleagues
and discuss a variety of
improvement topics over
breakfast! Special Interest
Breakfasts (SIBs) are informal
group conversations led by
an expert facilitator.
Wednesday, December 11 • 7:00 AM – 7:45 AM
SIB5: How Communities and
Health Care Organizations Can
Support Conversations about
Preferences for End-of-Life
Care
SIB12: When “Front-Line”
means “Proximity to the
Enemy”: Does the Language
We Use Convey What We Do?
Grand Ballroom, Salon 4-6
Facilitator: Tester, C., Strategic Lead for Third Sector
Engagement and Partnership, Scottish Government,
NHS Scotland
Facilitator: McCutcheon Adams, K., LICSW, Director, IHI
SIB6: IHI’s Work in Latin
America
Crystal Ballroom, Salon P-Q
Facilitator: Delgado, P., Executive Director, IHI
SIB1: IHI’s Passport Program
Anaheim
Facilitator: Duncan, K., RN, Faculty, IHI
SIB2: The AHRQ Health Care
Innovations Exchange: Sharing
Innovative Solutions and Tools
to Improve Quality and Reduce
Disparities
Crystal Ballroom, Salon K-M
SIB14: Why Science is
Important for Improvement
Facilitator: Ettinger, J., President and CEO,
Category One, Inc.
Facilitator: Samis, S., Vice President, Programs, CFHI
Crystal Ballroom, Salon A-C
SIB8: IHI Triple Aim Initiative:
High-Risk, High-Cost
Populations
Crystal Ballroom, Salon N
Whittington, J., MD, Lead Faculty,
Triple Aim Initiative, IHI
SIB3: Facilitating Appropriate
Antibiotic Use: Incorporating
Interventions into the Work
Flow of Hospitalists
SIB9: Patient Engagement
across the Continuum
SIB4: New Designs for Population
Health Management: Lessons
from the IHI Triple Aim
32
Grand Ballroom, Salon 12-14
Facilitator: Carpenter, D., RN, Innovations Exchange
Project Manager, WESTAT
Facilitators: Srinivasan, A., MD, Medical Epidemiologist, Center for Disease Control and Prevention;
Flanders, S., MD, Professor of Medicine, University of
Michigan Hospital and Health System; Jacobsen, D.,
Director, IHI
SIB13: Canadian Foundation for
Healthcare Improvement (CFHI):
Accelerating Health Care
Improvement
SIB7: Baldrige-Guided
Excellence: It Works
New York/New Orleans
Chicago/Denver
Grand Ballroom, Salon 3
Facilitator: Barber, N., Director of Research,
The Health Foundation
Grand Ballroom, Salon 9-10
Facilitator: Powell, J., Technical Advisor,
Aligning Forces for Quality (AF4Q) Initiative
SIB10: Hospital Engagement
Network (HEN) Breakfast
Crystal Ballroom, Salon G
Facilitator: Luther, K., RN, Vice President, IHI
SIB11: Joining Forces to Better
Manage Population Health
Grand Ballroom, Salon 1-2
Grand Ballroom, Salon 7
Facilitators: Feeley, D., Executive Vice President, IHI;
Nolan, T., Statistician, Associates in Process
Improvement and Senior Fellow, IHI
Facilitator: Petry, J., Vice President, Strategic
Initiatives, Premier Healthcare Alliance
25th Annual National Forum on Quality Improvement in Health Care
CONFERENCE DAY 2
Wednesday
DECEMBER 11
keynote three
8:00 AM – 9:00 AM
Cypress Ballroom 3
Rapid Fire Workshops
10 minutes, 10 slides
In these fast-paced sessions, presenters will have
10 minutes to present 10 slides on the topics
listed below.
RFD: Innovations in Health
Information Technology
Grand Ballroom, Salon 4-6
Moderator: Hamnett, P., Vice President
of Engineering, IHI
Presenters: Galli, B., Industrial Engineer, North
Shore – LIJ; Davis, N., Program Director, Clinical
Information and Research, Providence Health
and Services; Woebbeking, L., Quality Improvement
Manager, Grundy County Memorial Hospital; Dolin, J.,
Founder, Emmi Solutions; Ferrans, R., MD, Physician
Executive, Presence Health
RFE: Beyond the Walls:
IHI Triple Aim Collaborations
with Community Leaders
Grand Ballroom, Salon 4-6
Moderator: Lewis, N., Director, IHI
Nancy Snyderman, MD, Chief
Medical Editor, NBC News,
interviewing her patient,
Lindsay Beck, a two-time
cancer survivor
Presenters: Kramer, S., Project Manager, Cincinnati
Children’s Hospital Medical Center; Gray, R., RN, Head
of Early Years Collaborative, Scottish Government;
Guy, M., Managing Director, Pueblo Triple Aim
Corporation; Bennett, J., Executive Director,
The Family Van
if the patient is low-risk and thus eligible to be
placed on observation status instead of being
admitted. Avoiding inpatient stays lowers the risk
of infection, improves patient experience, and
lowers costs.
After this session, participants will be able to:
• Develop innovative decision support protocols
that impact IHI Triple Aim outcomes
• Describe an organization where physician
and operational collaboration enables and
encourages medical advancement alongside
organizational efficiencies
Leiterman, G., Vice President, Operations and Hospital
Specialty Services, HealthPartners; Moriarty, K.,
Medical Director, CHF Clinic and Research,
HealthPartners Medical Group
(D workshops continued on next page)
special interest
keynotes
D1: The Role of Leaders
in Building a Culture of
Continuous Improvement
9:30 AM – 10:45 AM
Cypress Ballroom 3
D/E workshops
Storyboard Walkarounds
Cypress Ballroom 1
NEW! Take a walking tour of some of the
exceptional storyboards submitted this year.
Each session will include a moderator and
storyboard presenters will stand beside
their boards to answer questions.
SWD: Process and Outcome Measures from
the Partnership for Patients
D workshops
Shahab Saeed, Vice President & COO,
Questar Energy Services
E workshops
E1: Environmental Sustainability
and the IHI Triple Aim
9:30 AM – 10:45 AM
11:15 AM – 12:30 PM
11:15 AM – 12:30 PM
Cypress Ballroom 3
All D workshops repeat during
E workshops except for special
interest keynotes.
Moderator: Connors, B., Student, University of
Michigan Medical School
Presenters: : Lemon, V., RN, Project Lead, Children’s
National Medical Center; Baldassarre, D., RN, Oncology
Clinical Nurse Specialist, Canter Treatment Centers
of America®; Raphael, C., RN, Critical Care Coordinator, NCH Healthcare System; Rhee, C., MD, Assistant
Professor, UT Southwestern Medical Center
SWE: Leveraging Technology
Moderator: Priest, K., Student, Portland State
University School of Community Health
Presenters: Clark, K., Regional Chief of Optometry,
Kaiser Permanente; Sharma, M., Clinical Librarian,
London Health Sciences Centre; Preese, L.,
Quality/Business Manager, Regions Hospital;
Lozano, M., Senior Quality Engineer, UT MD Anderson
Quality, Cost, and Value
D2/E2: Cardiac Protocol:
Improving Health, Reducing Costs F
Grand Ballroom, Salon 1-2
In the six months since implementation,
Regions Hospital’s innovative low-risk heart
failure protocol has decreased patient admissions
by 35 percent and reduced costs by 80 percent.
The protocol utilizes decision support tools built
into the electronic health record to help determine
Donald Berwick, MD, MPP, President
Emeritus and Senior Fellow, IHI
Moderating a panel including:
Blair Sadler, Senior Fellow, IHI
Gary Cohen, Executive Director,
Health Care Without Harm
Robin Guenther, CEO, Perkins+Will
Consulting Practice
Jeffrey Thompson, MD, CEO, Gundersen
Health System
33
CONFERENCE DAY 2
Wednesday
DECEMBER 11
• Develop an action plan to use the lessons
from this session to work toward achievement
of the IHI Triple Aim for improving primary
care delivery
Gelmon, S., DrPH, Professor of Public Health, Portland
State University; Merrithew, N., Director, PCPCH
Program, Oregon Health Authority; Christensen, M.,
Executive Director, Oregon Health Care Quality
Improvement Capability
D5/E5: Beyond the CEO: Sustaining
ThedaCare’s Culture M
New York/New Orleans
D3/E3: Lowering Cost, Increasing
Value: Starting Points and
Approaches for Success
Grand Ballroom, Salon 7
This session will provide participants with several
frameworks to set up their organization for
success with respect to understanding their
costs of care and improving value for their
patients. Participants will learn basic approaches
and ways to apply them to their own setting.
After this session, participants will be able to:
• Develop a framework for their organization to
successfully reduce cost and improve value
• Describe uses for value stream mapping in
understanding patient flow and related costs
• Explain the principles of Time-Driven Activity
Based Costing (TDABC)
Luther, K., RN, Vice President, IHI; Schilling, L., RN,
National Vice President, Healthcare Performance
Improvement, Kaiser Permanente; Haas, D., Senior
Project Leader, Harvard Business School; Liu, M., MD,
Physician, Southern California Permanente
Medical Group
D4/E4: Primary Care Transformed
to Improve Oregon’s Health F
Crystal Ballroom, Salon G
As part of its strategy to achieve the IHI
Triple Aim, Oregon has implemented the
Patient-Centered Primary Care Home (PCPCH)
program. Rapid rollout to over 350 primary
care clinics statewide has been supported by
a learning collaborative designed to advance
practice transformation. Implementation
approaches are being studied to identify early
successes and immediate opportunities for
improvement. This session will highlight Oregon’s
model, implementation strategies, evidence of
effectiveness, and lessons learned to improve
health and health care while lowering costs.
After this session, participants will be able to:
• Describe the facilitators of implementation
of the PCPCH, as well as the barriers
to implementation
• Identify opportunities for replication and
application of lessons from the Oregon
PCPCH experience for state governments,
broad-scale initiatives, and clinics in other
organizations and regions
34
When the CEO retires or leaves, an organization
changes. The culture of improvement can be
destroyed overnight by the new leader. Lasting
change requires that organizations hardwire
improvement thinking into succession candidates.
It also requires board commitment to choosing
internal candidates with the characteristics
required to accelerate the improvement journey.
In this workshop, ThedaCare’s former CEO, John
Toussaint, and present CEO, Dean Gruner, will
describe the process of sustaining an improvement
culture that outlives the tenure of any one CEO.
After this session, participants will be able to:
• Identify the standard work for succession
planning that senior management and
boards use to choose leaders
• Implement a management system that
hardwires improvement skills into all
succession candidates
Toussaint, J., MD, CEO, ThedaCare Center for
Healthcare Value; Gruner, D., MD, President
and CEO, ThedaCare
D6/E6: Achieving Results at Scale:
Building Capability and Capacity
for Improvement Across a Region
Sawgrass
As we increasingly seek to improve the health
of populations at the regional level, how do
we build a workforce that has the capacity to
make effective change and is capable of
understanding and applying improvement and
innovation methodologies? In this workshop,
participants will learn from existing efforts to
improve health care at a regional or country
level to build capacity and capability to achieve
improved patient outcomes.
After this session, participants will be able to:
• Identify approaches to developing capacity
and capability for improvement and innovation
at a regional level
• Derive strategies for motivating and creating
a high-performing workforce for innovation
and improvement
Mate, K., MD, Vice President, IHI; Richmond, M.,
Chief of Clinical Affairs, Hamad Medical Corporation;
Ruelas, E., Senior Fellow, IHI; Davis, H., General
Manager, Ko Awatea, Counties Manukau District
Health Board
D7/E7: Closing the Knowing-Doing Gap
Crystal Ballroom, Salon D
Six frogs are sitting on a lily pad, and one decides
to jump. How many frogs are left on the lily pad?
Six—because “deciding” and “jumping” are
different verbs. Is your leadership team made up
of well-intentioned frogs or jumping frogs? Is your
leadership team aligned in its leadership mindset, goals, and resources? Does your organization
hold people accountable for executing well? In
this workshop, you will learn evidence-based
leadership practices that will help you jump over
the quality chasm.
After this session, participants will be able to:
• Identify the barriers to improvement that are
keeping their leadership team on the lily pad,
as well as the opportunities for improvement
being missed
• Implement three evidence-based practices
that will improve their ability to execute
system goals
Deao, C., Senior Leader, Studer Group
D8/E8: Emergency Department
Clinical Information Manager:
The Scribe Program
Grand Cayman/Puerto Rico
The mission of the Scribe Program is to facilitate
and to expedite emergency department patient
flow by allowing providers to spend more time
on direct patient care and education while
concurrently producing more thorough and
higher-quality documentation. Among the topics
discussed in this workshop will be operational
improvement, patient satisfaction, physician
satisfaction, education, and financial performance.
After this session, participants will be able to:
• Educate health systems, academic medical
centers, and community hospitals about the
benefits and challenges of implementing
a clinical information manager-scribe program
• Create a model for a homegrown clinical
information manager and scribe program
Raj, P., Vice President of Clinical Informatics, Emergent
Medical Associates; Ferrigno, R., Chairman, Department
of Emergency Medicine, Bridgeport Hospital
D9/E9: Measuring Improvement F
Crystal Ballroom, Salon H
How do we know that a change is an
improvement? Many teams struggle to select an
effective set of measures to track improvement,
without missing important trends or getting lost
in a host of irrelevant data. This session will
present a structured approach to answering
the “measurement question,” beginning with
an explicit theory of improvement, priorities for
interventions, and identification of key outcome
and process indicators. We will also review
the relationship between outcome measures,
project measures, and Plan-Do-Study-Act
(PDSA) measures.
25th Annual National Forum on Quality Improvement in Health Care
After this session, participants will be able to:
• Differentiate measurement for improvement
from measurement for research
• Use a driver diagram to identify key
interventions and associated measures
• Discuss the relationship between process
and outcome measures and identify critical
measures needed to track improvement
Scoville, R., PhD, Improvement Advisor and
Consultant, IHI
D10/E10: Principles and Pitfalls
for Running Breakthrough Series
Collaboratives
Grand Ballroom, Salon 9-10
Breakthrough Series (BTS) collaboratives can
be a powerful tool for spreading improvements
in organizations, communities, and regions, but
only if established design principles are used and
common pitfalls are avoided. Using a wide range
of examples, this session will cover everything
from selecting a topic, building change packages,
measurement systems, engaging teams, and running robust learning sessions and action periods.
Participants will gain a deeper understanding of
the BTS method, including what to consider in
making adaptations to the traditional model and
how to diagnose and address common issues
and challenges.
After this session, participants will be able to:
• Apply established design principles for
successful BTS collaboratives
• Diagnose and address the common issues and
challenges that arise using the BTS method
Schall, M., Senior Director, IHI; Murray, S.,
Improvement Advisor, CT Concepts;
McCutcheon Adams, K., LICSW, Director, IHI
D11/E11: Teams and Technology:
Transforming Care as We Know It F
Grand Ballroom, Salon 12-14
This session will look at the way we develop care
teams and leverage health information technology
to transform the way we deliver care. A group of
multidisciplinary leaders at Kaiser Permanente will
discuss how care teams have become better able
to use process improvement and technology while
including patients in care improvement projects.
Through interactive exercises, participants will
translate key principles and learnings to various
organizational structures and care settings.
After this session, participants will be able to:
• Identify how to develop effective care teams
that can leverage advanced health
information technology
• Explain how teams can use health
information technology to accelerate
their ability to transform care and become
skilled in process improvement
• Apply core principles and learnings of
technology-supported care teams in
their own organization
Chow, M., PhD, RN, Vice President, National Patient
Care Services, Kaiser Permanente; Fredriks, D.,
PharmD, Director of Clinical Pharmacy Services,
Kaiser Permanente
D12/E12: Why So Slow?
Spreading Success for Leaders
D14/E14: Emergency Care of Frail
Older People
Crystal Ballroom, Salon N
Crystal Ballroom, Salon P-Q
Why is it difficult to spread the excellence
achieved in one area of a system throughout
the system? The keys to doing so lie in unlocking
delays to adoption and in reliable implementation
at scale. This session will provide participants with
an approach and a toolkit for spread. Participants
will learn by doing in an interactive way and come
away with how-to knowledge and practice on the
key components for spread. Faculty from three
high-performing systems from around the world
will lead and share approaches and examples.
Increasing numbers of older people are seeking
emergency care in hospitals and other settings
across the world. This has resulted in negative
outcomes for older people in emergency departments (EDs) and following hospital admissions.
It is time to rethink the paradigms for health and
social care for the future from the perspectives
of older people, their careers, and society.
Participants in this workshop will learn what to
consider when trying to understand the needs
of frail older people in order to offer the most satisfying, appropriate, timely, and effective responses.
After this session, participants will be able to:
• Develop an approach to get the best care
in their system reliably spread throughout it
• Test (and later teach) this approach
to spreading excellence
Henriks, G., Chief Executive of Learning and
Innovation, The County Council of Jönköping;
Compton-Phillips, A., MD, Associate Executive
Director, Quality, Kaiser Permanente;
Longmate, A., MB ChB, National Clinical Lead
for Patient Safety, Scottish Government
Triple Aim for Populations
D13/E13: Delivering Value Through
Emergency Department–Medical
Home Coordination
Crystal Ballroom, Salon K-M
Saint Francis Care and Dartmouth-Hitchcock
Medical Center launched an initiative to improve
health through a value-oriented approach that
coordinates care across the emergency medicine–primary care continuum at these two very
different sites. The teams have worked together to
achieve a consistent set of aims and demonstrate
that one size does not fit all when implementing
innovation at the local level. In this workshop,
these teams will share insights and tools for
better understanding patient utilization and
improving coordination.
After this session, participants will be able to:
• Identify approaches to understanding
patient patterns and preferences in their
emergency department (ED)
• Utilize an awareness of the tools and
technology that help reduce low-value ED
encounters and improve care coordination
• Recognize the benefit of a patient-centered
ED registry in delivering value to high users
Makoul, G., PhD, Chief Academic Officer and Senior
Vice President for Innovation, Saint Francis Health
System; Curtis, K., MD, Program Director, Emergency
Medicine Residency, Dartmouth-Hitchcock
Medical Center
After this session, participants will be able to:
• Identify frail older people in the ED
• Implement quality care for older
people in EDs
Banerjee, J., Consultant in Emergency Medicine,
University Hospitals of Leicester NHS Trust;
Carpenter, C., MD, Assistant Professor, Emergency
Medicine, Washington University in St. Louis
D15/E15: Successes in the Journey to
Improve Health Equity
Chicago/Denver
In order to provide more culturally-responsive
care to an increasingly diverse patient population,
new partnerships across the care continuum are
necessary. At Kaiser Permanente, attempts to
address the “total health” of the patient have
benefited from the creation of interdisciplinary
care teams with members ranging from nursing
to operations, service, and risk. Promising best
practices with multiple cross-site pilots have
also been demonstrated in partnerships with
barbershops, health navigators, and community
health centers. Participants in this workshop
will learn how to leverage the best practices
developed across these multiple sites to
improve health equity.
After this session, participants will be able to:
• Identify culturally appropriate tools that address
the mental, social, and behavioral health of the
individual while also improving population care
• Implement strategies to engage interdisciplinary care teams within the community to
improve patient health outcomes
Wong, W., MD, Clinical Director, Kaiser Permanente;
Gould, B., RN, Senior Director, Quality, Hospital
Oversight, Kaiser Permanente
D16/E16: Transitioning into a New
Model of Care: One Year Post-IHI
National Forum
Marco Island
One year after incorporating the changes
proposed at the 2012 IHI National Forum, the
model of care at Ochsner Clinic had achieved
substantial gains in service (resulting in a 96
percent rate of patient satisfaction) and access
(removing system and self-imposed barriers
related to providers’ schedules to more frequently
(continued on next page)
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35
CONFERENCE DAY 2
Wednesday
DECEMBER 11
keynote four
what they need—no more and no less.
After this session, participants will be able to:
• Describe the six steps of shadowing as a
standardized, simple mechanism to improve
care experiences and outcomes, remove
waste, and decrease costs
• Use shadowing to define exactly what patients
want and need while engaging staff in the
redesign of care delivery
• Achieve the emotional connection with
patients that can drive change efforts
DiGioia, A., MD, Medical Director and Surgeon,
PFCC Innovation Center, University of Pittsburgh
Medical Center (UPMC); Schraeder, L.,
Organizational Development Consultant, UPMC
1:30 PM – 2:30 PM
D18/E18: Storytelling: The Why
and the How P
Cypress Ballroom 3
Grand Ballroom, Salon 3
Stories have the power to engage hearts and
minds and to bring diverse interests together
around common goals. Sharing their experiences
of collecting and sharing stories in a variety of
settings, faculty in this workshop will discuss how
to tell a story and when sharing is most effective.
Participants will learn about ethnography, social
media, and ways to harness patient and family
stories as well as those of staff and clinicians.
Donald Berwick, MD, MPP,
President Emeritus and
Senior Fellow, IHI
provide same-day access). These gains have led
to an increase in visits while lowering cost, while
also increasing capitation allocation. In this session, you’ll learn what Ochsner took home after
last year’s National Forum, and what exactly they
did to see such great results only one year later.
After this session, participants will be able to:
• Articulate the challenges moving from a
volume-based to a value-based practice
• Consider changes that worked for Ochsner
that might also work in their own setting
Genzer, K., Chief Operating Officer, Ochsner Clinic;
Hart, R., MD, Regional Medical Director, Ochsner Clinic
Person- and
Family-Centered Care
D17/E17: Go Shadow: See
Patients’ Wants and Needs
While Lowering Costs S
Grand Ballroom, Salon 8
Shadowing patients and families is a powerful
mechanism for identifying opportunities to
transform patients’ care experiences as well as
clinical and operational outcomes while reducing
waste and cost. Shadowing creates co-design
partnerships with patients and families and
harvests the power of staff engagement in care
redesign. This session will teach participants how
to use shadowing to provide patients with exactly
36
After this session, participants will be able to:
• Describe the role of stories in accelerating
change and improvement
• Develop a powerful case for integrating
stories into their setting
• Describe the most effective story formats
for different audiences
Hayward, M., Lead, Patient and Family Engagement,
IHI; Haskell, H., President, Mothers Against
Medical Error; Chase, A., Senior Vice President,
Medicare Clinical Operations and Population
Care, Kaiser Permanente
D19/E19: Student- and ResidentDriven Patient Safety Programs F S
Vinoy
Medical students and residents from around
the country who attend the Telluride Educational
Roundtable have the opportunity to learn about
patient safety and medical quality and collaborate
on projects under development at their home
institutions. This workshop will feature student
and resident participants from the last eight years
of the program discussing projects they initiated
and will provide an opportunity for participants
to discuss how to design similar programs at
their own organizations.
After this session, participants will be able to:
• Articulate examples of student- and
resident-driven medical quality initiatives
• Discuss strategies for implementing
collaborative models in undergraduate
and graduate medical education settings
Mayer, D., MD, Corporate Vice President, Quality and
Safety, MedStar Health; Kantrowitz, M., DO, Physician,
Maimonides Medical Center; Levy, P., Author;
Hatoun, J., Resident, Boston Medical Center;
Morrison, K., Medical Student, University of
Missouri at Columbia; Grandhi, R., Medical Student,
University of Cincinnati
D20/E20: Caring for Maria:
Improving Things That Matter
in Ambulance Service
Anaheim
Ambulances treat and transport an estimated
16 million patients to emergency departments
annually. The 2006 Institute of Medicine report
“EMS at the Crossroads” recommended
developing evidence-based care and effective
measurement for emergency medical service
(EMS). In this workshop, participants will learn
how American Medical Response, the largest
ambulance provider in North America, is leading
a national improvement collaborative to reduce
harm and improve care outcomes while sharing
its results with the industry.
After this session, participants will be able to:
• Discuss the development of measurement
and change ideas in an innovation space
• Recognize the elements of a sustainable
national improvement collaborative system
• Identify the individual and organizational
challenges of executing improvement in
the EMS setting
Williams, D., PhD, Improvement Advisor, TrueSimple
Consulting; Bourn, S., PhD, Vice President of Clinical
Practices and Research, American Medical Response;
Taigman, M., General Manager, American Medical
Response; White, L., National Director of Resuscitation
and Accountable Care, American Medical Response
D21/E21: Code Red: A Team-Based
Approach to Surgical Fire Prevention
Miami
Surgical fires continue to be a preventable and
serious source of patient injury in the United
States. The ECRI Institute estimates that as
many as 650 surgical fires occur annually, often
resulting in second- and third-degree burns or,
in the case of airway fires, more serious injuries
or death. Most, but not all, of these patient injuries
occur in the setting of surgery, where a coordinated team-based effort is required to eliminate
this hazard. This workshop will focus on the
scope of the problem and offer a multidisciplinary
strategy to address it.
After this session, participants will be able to:
• Identify scenarios of high risk of fire injury
• Implement team strategies in complex
surgical environments
Hannenberg, A., Board Chair, Council on Surgical and
Perioperative Safety; Constantine, R., PhD, Assistant
Director of Mid-Level Practitioners, Saint Francis
Hospital; Dagi, T., MD, Director and Chief Medical
Officer, Prismic Pharmaceuticals
D22/E22: How Safe Are You? Harm
Measures Panel Discussion M
Grand Ballroom, Salon 11
There is much debate as to how to determine
how safe our systems are. In this session, a
panel of experts will describe different harm
25th Annual National Forum on Quality Improvement in Health Care
measurements and share with participants,
in an interactive discussion, ways to apply
them in their own institutions.
D25/E25: Scotland’s Quality Journey
After this session, participants will be able to:
• Describe the different approaches to
measuring harm in systems
• Discuss the advantages and disadvantages
of these harm measurements
Six years ago, the political leaders, the clinicians,
and the managers of Scotland’s health care system
set out on an ambitious journey to reduce mortality
and harm. Success in that effort led to a more
ambitious and broader approach to health care
quality that goes beyond safety and, more recently,
even beyond health care. This session will describe
what Scotland did, by what method, and the
lessons learned. Participants will have an
opportunity for interactive learning, including
applications to their own settings.
Federico, F., RPh, Executive Director, Strategic
Partners, IHI
D23/E23: Measuring Harm in the
UK National Health Service
Aruba/Bahamas
In 2011 the National Health Service (NHS)
England embarked on an unprecedented
journey to devoting one day per month to measuring harm proactively on all NHS patients. The
measurement instrument, known as the NHS
Safety Thermometer, has now been used on
over 2 million NHS patients. In this session,
presenters will share some of the data from this
data collection system, as well as lessons learned
from establishing this system for measuring harm.
After this session, participants will be able to:
• Identify the challenges of measuring safety
at scale
• Describe the design principles of the safety
measurement system known as the NHS
Safety Thermometer
• Use the lessons learned from the implementation of this large-scale change initiative
Power, M., Director, Salford Royal Hospital
Foundation NHS Trust; Warren, A., Project
Manager, Department of Health, United Kingdom
D24/E24: Reliable Application
of Sepsis Bundle Elements
Crystal Ballroom, Salon J
The North Shore–Long Island Jewish Health
System (North Shore–LIJ) has partnered with
IHI to conduct a multi-hospital collaborative
focused on increasing the reliability of sepsis,
severe sepsis, and septic shock bundle elements. Focused on the emergency department
and the medical/surgical floors, the work has
resulted in significant improvement in process
measures and clinical outcomes. In this session,
faculty will discuss the methodology, results, and
hurdles, along with the methods that were
successful in this work.
After this session, participants will be able to:
• Identify barriers to improving front-line
implementation of key elements of the
sepsis bundle
• Develop new processes that decrease
delays in the care of patients with severe
sepsis and shock
D’Angelo, J., MD, Senior Vice President, Emergency
Services, North Shore–LIJ; Doerfler, M., MD, Senior
Vice President, Clinical Strategy and Development/
Associate CMO, North Shore–LIJ; Parmentier, D., RN,
Director, Critical Care, Telemetry, and Emergency,
Glen Cove Hospital; Jacobsen, D., Director, IHI
Harbor Beach
After this session, participants will be able to:
• Assess the impact of Scotland’s national
quality improvement change program
• Apply the lessons learned from Scotland to
their own work to achieve change at scale
Leitch, J., Clinical Director, Quality Unit, Scottish
Government Health Department; Feeley, D.,
Executive Vice President, IHI
D26/E26: Using Evidence to Prevent
Falls: Skilled Nursing
Crystal Ballroom, Salon E-F
The three skilled nursing facilities of the
North Shore–LIJ Health System (North Shore–LIJ)
have reduced patient falls with injuries to far
below state and national benchmarks by using
an interdisciplinary team approach and engaging
patients/residents and families in risk reduction
strategies. This workshop will present some of
the evidence-based practices adopted by North
Shore–LIJ, including strict monitoring of high-risk
patients/residents, shift-to-shift walking
rounds, physical therapist consults, and
reductions in psychotropic medications.
After this session, participants will be able to:
• Identify five evidence-based practices that
were adopted at North Shore–LIJ to prevent
patient/resident falls
• Describe how patients and families are engaged
in strategies for reducing the risk of falls
Geraghty, B., RN, Associate Executive Director, Patient
Care Services, Stern Center for Rehabilitation; Grogan,
M., RN, Associate Executive Director, Patient Care
Services, Orzac Center for Rehabilitation, Healy, M., RN,
Chief Nursing Officer, Broadlawn Manor Nursing and
Rehabilitation Center
D27/E27: Building an Integrated
Outpatient Safety Net Program
Crystal Ballroom, Salon A-C
This workshop will discuss the right way to build
a centralized surveillance system—including
leveraging data, electronic tools, and a modest
staff to address a variety of clinical situations
where ambulatory patient safety is at risk.
After this session, participants will be able to:
• Identify where opportunities are to systematically
address patient safety issues outside of
the traditional inpatient setting
• Target specific patient populations within two
primary areas of out patient safety: Medication
safety/ diagnosis detection and follow-up care
• Develop an outpatient safety program by
creating a series of centralized safety nets
to catch errors
Kanter, M., MD, Medical Director, Quality and Clinical
Analysis, Kaiser Permanente Regional Quality and
Risk Management; Smith, A., Regional Safety Net
Consultant, Southern California Permanente
Medical Group
Wednesday
SPECIAL EVENTS
Simpler Healthcare Vendor Presentation:
Lean Leadership Immersion for Health Care
10:45 AM – 11:15 AM • Palms Foyer Classroom
You may know Lean tools are only part of the solution to transforming your entire workplace.
What do you know about the pivotal role leaders play in getting beyond use of the tools and
changing the behavior of the entire organization? What is the essential short list of things leaders
do to make the difference in capturing the hearts and minds of all employees? Come find out in
this 30 minute session led by Simpler Healthcare.
Institute for Enterprise Excellence (IEX) Vendor Presentation:
Lean Health Care, Enterprise Excellence, and The Shingo Model
12:45 PM – 1:15 PM • Palms Foyer Classroom
IEX—founded by Jacob Raymer, an HVN Board Member and former Executive Director of
Education for the Shingo Prize— provides management systems, research, learning resources,
and thought leadership to the health care industry. This session will describe how systems,
principles, and cultural enablers are used to identify strategic gaps and develop strategic/
operational roadmaps. “The knowledge gained from this [approach] is truly a game changer”—
Cleveland Clinic. Join us to hear more.
What workshop are you enjoying? Tweet it using #IHI25Forum
37
SHUTTLE
Map
Conference
Headquarters
38
25th Annual National Forum on Quality Improvement in Health Care
cfhi-fcass.ca
Education for today’s
healthcare leader
Explore CFHI’s distance learning and
face-to-face improvement workshops.
CFHI’s programs build your skills to help you improve
the way healthcare is organized, managed and delivered.
Enrollment begins December 2013. Program begins February 2014!
To view our catalogue or for
more information, visit cfhi-fcass.ca
Contact: Linda Piazza
Senior Director, Education and Training
[email protected] | 613.728.2328 ext 347
Please scan here to be
added to the mailing list.
The Canadian Foundation for Healthcare Improvement is a not-for-profit
organization funded through an agreement with the Government of Canada.
conference
Map
Patient and
Family Advisor
booth
This way to the North Tower
D
N
11
Bookstore
3
Registration
Changes &
Badge Edits
First Aid
Conference
Information
40
25th Annual National Forum on Quality Improvement in Health Care
conference
Map
Exhibit Hall &
Wellness Pavilion
Storyboards &
Luggage Storage
Keynote Room
Entrance
Registration
Presenter
Prep Room &
Lounge
Shuttles
Shuttle Service To:
Gaylord Palms Resort & Convention Center
Courtyard Orlando Lake Buena Vista in the
Marriot Village
Springhill Suites Orlando by Marriott
Caribe Royale
Buena Vista Suites
More details in Shuttle Map on page 38.
To Access
Complimentary
Wireless Internet:
1. Select “view available wireless
networks” and connect to the
“Marriott_CONF “
2. Open a new web browser and type
“ihi.org” into the address bar. You
will be redirected to the Marriott/
VreeHealth webpage.
3. Enter “IHI25FORUM” as the meeting
passcode and click “submit” (passcode is case sensitive.)
41
W H AT I F T H E R I G H T I N F O R M AT I O N F O U N D YO U ?
W I T H T H E D I G I TA L E N V E L O P E , I T C A N .
Sandlot Solutions understands exactly what information you need and
how to deliver it. Our fourth-generation health information exchange +
analytics combines clinical knowledge and claims data with business
intelligence to help you manage risk and demonstrate value.
Through our “digital envelope,” you receive compliance and evidencebased care alerts at the point of care, within your workflow. You get
high-level visibility to monitor quality measurements, patient outcomes
and population trends. And, of course, the digital envelope works with
our care manager platform or yours. All of this through the cloud.
Find us, and we’ll make sure the right information finds you.
Call 800-370-1393 or visit sandlotsolutions.com for more information.
42
25th Annual National Forum on Quality Improvement in Health Care
general conference
Information
Shuttle Service to Other Hotels
National Forum Bookstore
Guests
During the conference, IHI will provide National
Forum participants with complimentary shuttle
transportation to the Marriott World Center.
Shuttles will run every 10 to 20 minutes from
the following locations:
• Gaylord Palms Resort and Convention Center
• Courtyard Marriott Lake Buena Vista Hotel
• Marriott Village Springhill Suites
• Caribe Royale
• Buena Vista Suites
Located in the Crystal Foyer, the National Forum
Bookstore features books written, edited, or
recommended by our world-renowned faculty.
It will be open during the following times:
We are excited that family and friends are
accompanying many of you. We regret that
hotel space can accommodate only registered
participants at the keynote presentations,
general sessions, and meal functions. Your
guests are welcome to join you at the National
Forum receptions. Please see IHI staff at the
registration desk for a guest ribbon and
name badge.
See page 38 for shuttle map.
Shuttle Operating Hours
Sunday, December 8, 6:30 AM – 10:00 PM
Monday, December 9, 6:30 AM – 10:00 PM
Tuesday, December 10, 6:30 AM – 10:30 PM
Wednesday, December 11, 6:00 AM – 4:00 PM
IHI will also provide complimentary shuttle
service from the Marriott World Center to Orlando
International Airport on the last day of the General
Conference, Wednesday, December 11, from
12:00 PM to 4:00 PM.
Exhibit Hall Hours
The 2013 Exhibit Hall includes snack stations,
a new wellness pavilion, and over 130
exhibitors. The exhibit hall will be open in
the Palms Ballroom during the following times:
Monday, December 9
3:30 PM – 6:30 PM
Welcome Reception
4:30 PM – 6:30 PM
Tuesday, December 10
9:30 AM – 10:30 AM
(By appointment only)
10:30 AM – 1:30 PM
4:15 PM – 6:30 PM
Storyboard Reception
4:30 PM – 6:30 PM
Wednesday, December 11
Monday, December 9, 7:30 AM – 6:00 PM
Tuesday, December 10, 7:30 AM – 6:30 PM
Wednesday, December 11, 7:30 AM – 1:30 PM
Many of the National Forum Bookstore
authors will have scheduled a time for
book signings. These events will be
advertised around the conference
center and on Twitter using #IHI25Forum.
Business Center
Located next to the Palms registration desk
in the Crystal Foyer, the full-service business
center offers professional printing services as
well as shipping, receiving, copying, and faxing.
Business Center hours are:
Monday – Friday, 7:00 AM – 6:30 PM
Saturday – Sunday, 8:00 AM – 4:00 PM
Health Center
Message Board/Job Postings
Job postings and messages can be posted on the
corkboard located next to the registration desk
located in the Palms Foyer.
Messages and Faxes
If you are staying at the Marriott World Center,
your telephone messages will go directly to your
room. If a caller identifies you as being with the
National Forum, urgent messages will be posted
on the message board located next to the National
Forum registration desk near the Convention
Center entrance. Marriott World Center contact
numbers are:
Phone: 407-239-6411
The health center is a separate building on the
Marriott World Center property, located beyond
the pool. It is a fully equipped athletic facility with
indoor and outdoor pools, a full spa, whirlpools,
and saunas. The health center is open 24 hours,
with an attendant from 6:00 AM until 10:00 PM.
Use of the fitness center is complimentary for
overnight guests.
Guest Fax: 407-239-6164
Checkout
Unattended Belongings
Checkout from at the Marriot World Center is
at 11:00 AM. If you are staying at the Marriott,
please see the hotel bell staff about storing any
luggage after checkout. On the last day of the
conference, IHI Blue Shirts can help you check
your luggage in Cypress 1.
Please do not leave any personal belongings
unattended in meeting rooms. IHI is not
responsible for lost or stolen items.
Emergencies
If for any reason there is an emergency during
the National Forum, dial 55555 on any hotel
phone to be connected to security. IHI Blue
Shirt and Marriott World Center staff are also
available to assist.
Name Badges
Please wear your name badge throughout the
National Forum and carry your list of registered
sessions with you. This is your ticket into the
conference and all sessions.
Please Note
IHI will have video cameras and photographers at
the National Forum. We may capture your image
for use on IHI TV at the National Forum, on the
IHI website, or in other IHI materials.
10:30 AM – 1:30 PM
1:00 PM: Forum Fortune Drawing
at IHI Booth #301
43
general conference
Information
Green Initiatives
IHI continues to make a concerted effort to reduce the
environmental impact of the National Forum and all IHI events.
In year seven of this effort, you may notice the following changes:
• All presentations made available to IHI by presenters before the conference
will be available to participants on ihi.org. Participants need to log in and then
click on “My IHI” at the top of the screen, navigate to “My Enrollments and
Certificates,” and find the link under “25th Annual National Forum on
Quality Improvement in Health Care” for “Materials/Handouts.” Paper
handouts will not be provided for any session. If you would like paper
handouts, please print your materials before your arrival or visit printing
stations in the Los Angeles meeting room.
• Meeting materials are also available in the IHI Onsite app. Search the App
store or Android market for IHI Onsite.
• The entire meeting space will have high-speed wireless Internet access. We
encourage participants to bring their laptops to their sessions to take notes
and view presentations. Meeting rooms will be set up with work tables when
session capacity allows.
• IHI works with the conference center to eliminate waste from paper and
plastic food packaging and to use local and organic food products
whenever possible.
• Food not consumed by attendees will be donated to a local food bank.
• Exhibit Hall giveaways and other meeting supplies that are not distributed
will be donated to local elementary and middle schools.
• Recycling containers will be made available for recyclable meeting
materials and catering items.
• Transportation to the airport at the close of the conference will be available
to attendees in an effort to offset our carbon footprint by ride-sharing.
We encourage you to stop by the registration
desk to give us your feedback on how we
can continue to reduce the impact of the IHI
National Forum on the environment.
44
25th Annual National Forum on Quality Improvement in Health Care
FORUM
Fortune
You’ve Got to Play to Win
Visit each of these Forum Fortune Booth Sponsors, get their stamp or signature, and return your completed card to the IHI booth
by 11:30 AM on Wednesday, December 11. Drawing will be on Wednesday, December 11 at 1:00 PM at the IHI Booth (#301).
You must be present to win, and exhibitors are ineligible. Prizes include Apple gift cards, a Wii Fit, a Kindle Fire, Visa Gift cards,
an iPad, and a free registration to the 2014 National Forum, among others. You need stamps from each of these sponsors.
Ninon Koden
Booth #107
Amphion Medical Solutions
Booth #113
Navex Global
Booth #213
MCN Healthcare
Booth #316
DNV Healthcare
Booth #513
Dialog Medical
Booth #706
Dimensional Insight
Booth #801
Krames Staywell
Booth #815
Columbia Heartsource
Booth #817
Lightshed Healthcare
Technologies
Booth #914
National Database of Nursing
Quality Indicators
Booth #1002
MCG
Booth #1012
Medkinetics
Booth #1001
E
E
R
F
E
C
A
SP
Healthstream
Booth #1006
Sandlot Solutions
Booth #1013
Conifer Health Solutions
Booth #1200
CHG Hospital Beds
Booth #1201
VigiLanz Corporation
Booth #1206
Joint Commission Resources
Booth #1400
Care Team Connect
Booth #1418
Acesis
Booth #1424
Name:
Organization:
Email:
45
EXHIBIT HALL
Floor Plan
STORYBOARD
ENTRANCE
IHI
46
25th Annual National Forum on Quality Improvement in Health Care
CONTINUING
Education
Continuing Education
Attendees of the 25th Annual National
Forum on Quality Improvement in Health
Care will learn how to:
• Recognize habits that support
quality health care and apply the
basic principles for improving them
• Define ways to reduce suffering
and improve health
• Develop an understanding of how
to transform an organization
Identify elements for creating a culture
of change that will lead to continuous
improvement
In support of improving patient care,
the Institute for Healthcare Improvement
is accredited by the American Nurses
Credentialing Center (ANCC), the
Accreditation Council for Pharmacy
Education (ACPE), and the Accreditation
Council for Continuing Medical Education
(ACCME), to provide continuing education
for the health care team.
The National Forum carries a maximum
of 19.25 credits for physicians, nurses,
and pharmacists.
The Institute for Healthcare Improvement
designates this live activity for a maximum
of 19.25 AMA PRA Category 1 Credit(s)™.
Physicians should claim only the credit
commensurate with the extent of their
participation in the activity.
This program is approved by the National
Association of Social Workers (Approval
#886367066-2477) for 19 Social Work
continuing education contact hours.
All National Forum Learning Labs,
Minicourses, and General Conference
sessions offer ANCC, ACPE, ACCME,
and CPHQ credits except for the following
sessions, which offer ANCC, ACCME, and
CPHQ credits. Please note the exceptions
for ACPE below:
Sessions that do not offer
pharmacy contact hours:
L11, L20, L25, M14, M16, A4/B4, A7/B7,
A14/B14, A25/B25, C7, C8, C10, C12,
C27, D4/E4, D6/E6, D20/E20, D21/E21
Sessions that offer
social worker credits:
L3, L8, L11, L19, L22, L23, L24, L26, M6,
M10, M12, M15, M17, M18, M19, M20,
M22, M23, A2/B2, A8/B8, A10/B10,
A16/B16, A18/B18, A19/B19, A20/B20,
A21/B21, A22/B22, A23/B23, A25/B25,
B1, C1, C2, C6, C12, C13, C14, C15,
C17, C18, C19, C20, D4/E4, D13/E13,
D14/E14, D15/E15, D17/E17, D18/E18,
D27/E27, FE3, FE6
How to receive a
certificate of credit:
To be eligible for a continuing education
certificate, attendees must complete
the online evaluation within 30 days
of the continuing education activity.
If circumstances prevent you from
completing the survey by the specified
deadline, please email [email protected] before
this time period expires. After this time
period, you will be unable to receive a
continuing education certificate.
1. Go to ihi.org/certificatecenter.
(If you are not logged into the website,
you will be redirected to the log-in screen.
Once you are logged in, you will be
redirected back to the Certificate Center.)
2. Click on the “25th Annual National
Forum” link that appears under the
“Create Certificate” header.
3. Select the type of credits you wish
to receive from the drop-down list and
then click “Submit.”
4. Review your enrollment and
click “Continue.”
5. Take the surveys associated with
each of the sessions you attended and
for which you wish to receive credits
by selecting “Take Survey Now” next
to the session.
6. Once you have completed all of the
associated surveys, “Generate Certificate”
will be activated. Click on this button to
generate a PDF file of your certificate that
you can print or save to your computer.
47
STORYBOARDs
Storyboard Reception
Tuesday, December 10, 4:30 PM – 6:30 PM, Palms Ballroom
During this reception, presenters will be standing by their boards to answer questions.
Quality, Cost, and Value
QC1: A Flow Transformation
Fire Starter: Reducing Time to
Inpatient Bed
Cambridge Memorial Hospital
(Ontario)
Nisha Walibhai, RN
[email protected]
QC2: A RARE Approach to Reducing
Readmissions
Institute For Clinical Systems Improvement
Joann Foreman, RN
[email protected]
QC3: A Spine Model with
Demonstrable Cost Savings
HealthPartners
Bret Haake, MD
[email protected]
QC4: A Unique Approach to
Problem-Solving for Health Care
Guthrie Clinic
Vickie Kamataris, RN
[email protected]
QC5: Analytical Framework for
Improving Organizational Quality
Stetson University
Joseph M. Woodside
[email protected]
QC6: Applying a Tourniquet to
Blood Utilization
Franciscan Alliance
Beth Grbavac, RN
[email protected]
QC7: Applying Lean Acrross
the Continuum of Care
University Health Network
Sylvie Robinson
[email protected]
QC8: Applying Lean Concepts to
Health Care Processes
University of Texas, MD Anderson Cancer
Center
Pheba Philip
[email protected]
QC9: Applying Tracer Methodology
to Reduce Cardiac Surgery
Readmissions at Hospital of the
University of Pennsylvania
UPHS
Jo Anne Fante-Gallagher, RN
[email protected]
QC10: Benefits From Quality
Improvement to Increase Efficacy
of Rounding
Nationwide Children’s Hospital
Jeff Lewis, RN
[email protected]
QC11: Benefits of Managing
Low-Density Lipoprotein Particles:
A Cost-Effectiveness Analysis
S2 Statistical Soultions, Inc.
Peter Mallow, PhD
[email protected]
48
QC12: Bone Remodeling and Health
Care Reform
Kapiolani Medical Center for Women
and Children
Byron Izuka, MD
[email protected]
QC13: Bridging the Gap Between
Pharmacy and Nursing: The Value of a
Decentralized Pharmacy Technician
University of Connecticut
Amanda Miller
[email protected]
QC14: Butterworth Hospital Inpatient
Pharmacy: Improving Inventory
Management Throught LEAN
Spectrum Health
April Wolfe
[email protected]
QC15: Butterworth Hospital
Emergency Department: Using
Evidence Based Lean Practice to
Improve Quality and Throughput
Spectrum Health
Larah Wildern
[email protected]
QC16: Canton Warehouse: How
31,000 Unruly Square Feet
Accidentally Became a SystemWide Asset Storage Solution
Spectrum Health
Amy Sequeira
[email protected]
QC17: Care Coordination Redesign
Utilizing LEAN Six Sigma
Deaconess Hospital
Cathy Seuell, RN
[email protected]
QC18: Changing the Game Plan
for Discharge
NCH Health Care System
Marie Hageman, RN
[email protected]
QC19: Charcot Foot: A New
Integrated Pathway
Solent NHS Trust
Eloise Whitaker
[email protected]
QC20: Chasing Sepsis: Early
Recognition and Treatment of Sepsis
Outside of Critical Care
Hoag Memorial Hospital Presbyterian
Andre Vovan, MD
[email protected]
QC21: Clinical Operations Group
Franciscan Alliance
Beth Grbavac, RN
[email protected]
QC22: Colorado’s Critical Access
Hospitals and Rural Health
Clinics: Improving Communications
and Readmissions (iCARE)
Colorado Rural Health Center (CRHC)
Caleb Murphy Siem
[email protected]
QC23: Constant Collaboration:
Regional HFAP Program
Franciscan Alliance
Beth Grbavac, RN
[email protected]
QC24: Continuous Quality Improvement Process Using Heart Failure
Core Measures and Computer
Generated Palliative Care Triggers
NCH Health Care System
Shannon Brown
[email protected]
QC25: Creating One-Piece Flow in the
Primary Care Setting
University of Texas Medical Branch
Gina Butler, RN
[email protected]
QC26: Customizable, Office-Based
Surgical Safety Checklist Improves
the Rates of Key Indicators and
Outcomes
Institute for Safety in Office-Based
Surgery
Fred Shapiro, DO
[email protected]
QC27: Dated Color-Coded Labels Cue
Nurses to Adhere to Central Line
Connector Change
NCH Health Care System
Jan Foglesong, RN
[email protected]
QC28: Denials: The Path to Prevent
Payers from Saying No to Your Claims
Franciscan Alliance
Beth Grbavac, RN
[email protected]
QC29: Design, Implementation, and
Monitoring of Clinical Practice
Guidelines for Post-Surgical Pain
in Adult Patients
Hospital Universitario Austral
Ana Fajreldines, PharmD
[email protected]
QC30: Developing a Consistent
Method to Measure Ambulatory Space
Utilization Across a Pediatric Hospital
System
Cincinnati Children’s Hospital
Medical Center
Kathleen Kramer
[email protected]
QC31: Developing a Staffing Tool
for Clinical Leaders of Ambulatory
Cancer Centers
University of Texas, MD Anderson Cancer
Center
Tatiana Hmar-Lagroun
[email protected]
QC32: Discharge Planning: Bridging
the Gap Between Hospital and Home
Franciscan Alliance
Beth Grbavac, RN
[email protected]
QC33: Driving Transformation by Seeing the System Through the Eyes of
Patients and Their Families
Toronto Central Community Care
Access Centre
Jodeme Goldhar
[email protected]
25th Annual National Forum on Quality Improvement in Health Care
QC34: ED’s PAIN: Reducing
Musculoskeletal Pain-Related
Non-Urgent ED Visits by a
Cleveland VA Medical Home Clinic
Louis Stokes VA Medical Center
Mary Angelynne Esquivel, MD
[email protected]
QC35: Early Elective Deliveries: Rate
Improvement and Data Collection
Standardization
Carolinas Health Care System
Amy Bell, RN
[email protected]
QC36: Eliminating the NAUTI CAUTI:
Collaboration and Evidence Based
Protocols Drive Prevention Gains
NCH Health Care System
Maureen Baldia, RN
[email protected]
QC37: Embedding Care Managers
in Practice: A Michigan Tale
Michigan Primary Care Transformation
Project
Mary Ellen Benzik, MD
[email protected]
QC38: Empowering Physicians as
Change Agents
WhiteCloud Analytics
Jason Blumberg
[email protected]
QC39: Enhanced Patients’ Satisfaction
with Reduced Call Abandons
The Aga Khan University Hospital,
Karachi
Muhammad Taha Khan Bangash
[email protected]
QC40: Enhancing Satisfaction of
Patients by Decreasing Clinic’s
Length of Stay (LOS)
AGA KHAN UNIVERSITY HOSPITAL
Raheel Gujrati, MD
[email protected]
QC41: Epilepsy Monitoring Unit Care:
Using Evidence-Based Principles to
Improve Quality and Access to Care
Spectrum Health System
Holly Patterson
[email protected]
QC42: Evidence-Based Quality
Improvement Initiative Results in
Significant Decrease in HospitalAcquired Pressure Ulcers
Arrowhead Regional Medical Center
Frances Dyckman, RN
[email protected]
QC43: First Year Results of a
Performance Improvement Committee
for Extra-Corporeal Life Support
Houston Methodist
Sarah Homer, RN
[email protected]
QC44: From VAP to VAE: Implementing
the 2013 CDC/ NHSN VAE Guidelines
in Critical Care
NCH Health Care System
Chris Raphael, RN
[email protected]
QC45: Geisinger 7-Day Auto-Dialer
Improves Access and Revenue in
a Rural Integrated Health System
Geisinger Health System
John Kennedy, MD
[email protected]
QC47: Getting to 100%:
Standardizing Room Entry on the
Intensive Care Unit
Beth Israel Deaconess Medical Center
Samantha Ruokis
[email protected]
QC48: Going Vertical: Level 3
Fast Track
NCH Health Care System
Wendell McClurg, RN
[email protected]
QC49: Health Staff Capacity Building
in Rural Cambodia
NHS Thames Valley and Wessex
Leadership Academy
Claire Greszczuk
[email protected]
QC50: HFAP Preparedness: A
Frontline Focus
Franciscan Alliance
Beth Grbavac, RN
[email protected]
QC51: HFAP Standards: Identifying
Interactions
Franciscan Alliance
Beth Grbavac, RN
[email protected]
QC52: HFAP Survival Guide
Franciscan Alliance
Beth Grbavac, RN
[email protected]
QC53: Home Diuretic Protocol for
Heart Failure: Partnering with Home
Health to Improve Outcomes,
Reduce Readmissions
MaineHealth
Ann Cannon, RN
[email protected]
QC54: Home-Based Palliative Care
Program
Long Island Jewish Health System
Lori Attivissimo, MD
[email protected]
QC55: How to Gain MD Involvement in
OPPE and Re-credentialing
University of Texas, MD Anderson Cancer
Center
Alma Rodriguez, MD
[email protected]
QC56: How to Impact Quality with Top
Performing Hospital Best Practices
Truven Health Analytics
David Bordewyk
[email protected]
QC57: Identifying Waste in Surgical
Patients: Unscheduled Returns
to the Operating Room
Hospital Universitario Austral
Maria Teijeiro, MD
[email protected]
QC58: IMPACT DC: An Intervention
and Collaboration to Improve
Pediatric Asthma
AmeriHealth District of Columbia
Mark R. Fracasso, MD
[email protected]
QC70: Is Osteoporosis in Men
Under-Screened?
Cleveland Clinic Health System
Samta Jain, MD
[email protected]
QC59: Impact of Computer-Assisted
Personalized Sedation on Components
of Colonoscopy Procedure Time
S2 Statistical Soultions, Inc.
Peter Mallow, PhD
[email protected]
QC560: Improving OR Utilization and
First Case On-Time Starts
VA Eastern Colorado Health Care System
Adam Roberts
[email protected]
QC61: Improving Outcomes in Patients
with Complex Clinical Conditions:
Beyond 911
Long Island Jewish Medical Center
Rafael Barrera, MD
[email protected]
QC62: Improving the Subsidized
Specialist Outpatient Clinics’
No Show Rate and Optimizing
Utilization of Clinic Capacity
National University Hospital
Donna Joy B Penanueva, MD
[email protected]
QC63: Improving Throughput and
Patient Experience in the Emergency
Department Through Process
Improvement and Standardization
Sarah Bush Lincoln Health System
Nancy Wurtsbaugh, RN
[email protected]
QC64: Improving Time to Therapeutic
Vancomycin Trough
NCH Health Care System
Maria Esposito PharmD
[email protected]
QC65: Improving Transitional Care in
the San Francisco Bay Area
Cynosure Health
Pat Teske, RN
[email protected]
QC66: Increasing and Evaluating the
Value of Continuous Quality
Improvement Through the
LHSC Shared Governance Model
London Health Sciences Centre
Vanessa Burkoski, RN,, PhD
[email protected]
QC67: Innovation and Change in
Hard Times
University of Texas, MD Anderson
Cancer Center
Margaret Bell, RN
[email protected]
QC68: Integrated Care Pathway (ICP)
Programme for Patients with
Chronic Obstructive Pulmonary
Disease in JurongHealth
Alexandra Hospital (Jurong Health)
Anne Li Xiao
[email protected]
QC69: Integrating Supportive Care:
It’s Just What We All Do
OSF Health Care
Robert Sawicki, MD
[email protected]
QC71: ISO 9001 Standard: A Way to
Standardize Your Quality Program
Franciscan Alliance
Beth Grbavac, RN
[email protected]
QC72: Keep Pace with Racing Hearts:
Get with The Guidelines®-AFIB
American Heart Association
Louise Morgan, RN
[email protected]
QC73: Labor and Management
Partnering for Quality
1199 SEIU, RN Labor Management
Initiatives
Robbie Freeman, RN
[email protected]
QC74: Layout Analysis to Select
Transportation Equipment
Storage Locations at a Hospital
University of Texas MD Anderson
Cancer Center
Tatiana Hmar-Lagroun
[email protected]
QC75: Leveraging the Electronic
Health Record (EHR) to Reduce Occupational Exposure to Tuberculosis
NCH Health Care System
Georgine Kruedelbach, RN
[email protected]
QC76: Managed Care: Bridging
the Gap
Franciscan Alliance
Beth Grbavac, RN
[email protected]
QC77: Measuring Quality Impovement
in Palliative Care Provision in a
Tertiary Hospital
National Cancer Centre Singapore
Patricia Soek Hui Neo, MD
[email protected]
QC78: MEDS-Medication Education
Direct and Simple
NCH Health Care System
Annie Reynolds, RN
[email protected]
QC79: Mock Tracer Survey
Checklists: A Collaboration
Franciscan Alliance
Beth Grbavac, RN
[email protected]
QC78: Modified Resident Scheduling:
An Attempt to Reduce Length of Stay
Through Increased Provider Continuity
Mount Sinai Medical Center
Nicole Brown
[email protected]
QC81: Multi Disciplinary Process
Strategies Positively Affect Cardiac
Surgery Patients’ Blood Glucose
Virginia Commonwealth University
Debra Austin, RN
[email protected]
QC82: Next Generation MapsLink
Labor Costs to Waste
University of Texas, MD Anderson
Cancer Center
Gina Aranzamendez, RN
[email protected]
QC83: NQF’s Lean Journey:
Reimagining the Health Care
Quality Measure Development
and Endorsement
National Quality Forum
Adeela Khan, MPH
[email protected]
QC84: Nursing Resource Team: A
Resource for Quality Improvement
London Health Sciences Centre
Sandra Quin, RN
[email protected]
QC85: Objective Assessment of
Incoming Clinical Technology &
Devices
Geisinger Health System
A. Joseph Layon, MD
[email protected]
STORYBOARDS
QC46: Getting the Job Done:
Integrating Non-Health Professional
Students in Quality Assurance
Program Development and Review
London Health Sciences Centre
Margaret Belliveau, RN
[email protected]
QC86: Optimizing GI Patient Flow:
Procedure Room Turnover
BIDMC
Michelle Sheppard, RN
[email protected]
QC87: Our Journey to Standardized,
Evidenced-Based Practices for
Screening, Early Identification
and Intervention for Severe Sepsis
Sutter Health
Mary Ann Daly, RN
[email protected]
QC88: Outcomes Following Standardization of Discharge Processes for
Patients on Self-Administered OPAT
from a Safety-Net Hospital
Parkland Health and Hospital System
Kavita Bhavan, MD
[email protected]
QC89: Paradigm Shift in Takling
Annual Staff Competency
UPMC
Sherri Jones
[email protected]
QC90: Partnering Up: Partnership
for Patients
Franciscan Alliance
Beth Grbavac, RN
[email protected]
QC91: Pathology and Laboratory
Medicine: Reporting Patient Results
within Targeted Response Times
London Health Sciences Centre
Manuella Giuliano
[email protected]
QC92: Patient Comments Drive
Discharge Strategies
NCH Health Care System
Patty Haines, RN
[email protected]
QC93: Patient Satisfaction: Spreading
Best Practice
Franciscan Alliance
Beth Grbavac, RN
[email protected]
Which storyboard did you enjoy? Tweet it using #IHI25Forum
49
STORYBOARDs
Storyboard Reception
Tuesday, December 10, 4:30 PM – 6:30 PM, Palms Ballroom
During this reception, presenters will be standing by their boards to answer questions.
QC94: Paying it Forward: Interns for
Improvement
Franciscan Alliance
Beth Grbavac, RN
[email protected]
QC105: Reducing Harm from
Anticoagulant Therapy
NCH Health Care System
Maria Esposito PharmD
[email protected]
QC95: Pharmacist-Managed Antimicrobial Stewardship Program for Patients Discharged from the Emergency
Department (ED)
Memorial Hermann
Sara Schepcoff PharmD
[email protected]
QC106: Reducing Preventable
Readmissions by Leveraging
Real-Time Predictive Analytics
Integrated with a Workflow System
SpectraMD
Raj Lakhanpal, MD
[email protected]
QC96: Pharmacy Inventory Control
Quality Improvements
University of Texas, MD Anderson
Cancer Center
Dalia Farhat
[email protected]
QC107: Reducing Ventilator Days
Using Lean Six Sigma
Robert Packer Hospital
Nicole M. Teeter, RN
[email protected]
QC108: Reduction in CLABSI in
Children with Intestinal Failure
Through Implementation of a CLA-BSI
Prevention Bundle
Nationwide Children’s Hospital
Jeff Lewis, RN
[email protected]
QC97: Physician Scorecards:
Trending in the Right Direction
Franciscan Alliance
Beth Grbavac, RN
[email protected]
QC98: PI: Making a Digital Footprint
Franciscan Alliance
Beth Grbavac, RN
[email protected]
QC99: Putting on the Pressure:
Management and Prevention of
Pressure Ulcer for the Acute
Rehabilitation Patient
NCH Health Care System
Nancy Davison, RN
[email protected]
QC100: Quality & Effectiveness of
Electronic Wound Documentation
System (EWDS): Innovating for
the Future
Responsive Management Inc
Debbie Green
[email protected]
QC101: Quality Improvement for
Portable Chest X-Ray
Bumrungrad International
Punthika Karnsomdee, RN
[email protected]
QC102: Quiet in the House!
NCH Health Care System
Meredith Burt, RN
[email protected]
QC103: Rebooting Physician
Hardware Process
Franciscan Alliance
Beth Grbavac, RN
[email protected]
QC104: Reducing Costs & Improving
Quality
Franciscan Alliance
Beth Grbavac, RN
[email protected]
50
QC109: Reduction in Health CareAssociated Transmission of
Tuberculosis (Tb) to Health Care
Workers in Tertiary Care Hospital
The Aga Khan University Hospital
Suneina Musani
[email protected]
QC110: Room Occupancy
Management System (ROMS): Use
Them (Lights) or Lose Them (Patients)
Mayo Clinic
Andrew Majka, MD
[email protected]
QC111: Safe, Effective, & Well
Coordinated Patient Transition After
Total Joint Replacement: A “Discharge
Appointment”
MidState Medical Center
Dawn Plumb, RN
[email protected]
QC112: Same Day Discharge after
Pediatric Appendectomy:
Fast Track Appendectomy
All Children’s Hospital
Julie Messick, RN
[email protected]
QC113: Sepsis Identification/
Intervention: The Clock is Ticking
Franciscan Alliance
Beth Grbavac, RN
[email protected]
QC114: Slenderize Health Care Associated Infection Surveillance System
Bumrungrad International hospital
Junya Charayopas, RN
[email protected]
QC115: Smart Room Technology:
Giving Time Back to the Nurse
NCH Health Care System
Peter Olsen, RN
[email protected]
QC127: Trends in Disparities in Care
at Academic Medical Centers
University HealthSystem Consortium
Leslie Prellwitz
[email protected]
QC116: Something to Talk About:
Medication Education
NCH Health Care System
Dave Baryza, RN
[email protected]
QC128: Triaging Robotic Surgery
Based on Evidence-Based Clinical Outcomes Improves Resource Utilization
Banner Health System
David Edwards, MD
[email protected]
QC117: Staying Ahead of Falls
Franciscan Alliance
Beth Grbavac, RN
[email protected]
QC118: Strategies to Increase Awareness of Saturday Urgent Care Clinic
University Health Network
Miu Lin Wong
[email protected]
QC119: Stroke Care Excellence
to Achieve the Triple Aim:
Re-Engineered Preventive and
Hospital Care
Stanford Clinical Excellence
Research Center
Jared Conley
[email protected]
QC120: Supply Waste Reduction: A
Lean Six Sigma Improvement Project
Our Lady of Lourdes Regional
Medical Center
Cecile Broussard, RN
[email protected]
QC121: Systems and Human Factors
Engineering Approach to Reducing
CAUTI Health Care Associated
Infections
University of Texas Southwestern
Medical Center
Chanhaeng Rhee,, MD, MD
[email protected]
QC122: Teaching Personal Protective
Equipment (PPE) to Visitors
NCH Health Care System
Julie Amundson, RN
[email protected]
QC123: Team Approach to
Reducing Surgical Site Infections
in Hip and Knee Total Joint
Replacement Procedures
NCH Health Care System
Georgine Kruedelbach, RN
[email protected]
QC124: The Agency for Health Care
Research and Quality Health Care
Innovations Exchange (AHRQIX)
Westat
Deborah Carpenter, RN
[email protected]
QC125: Time is Muscle: Reducing
Harm with Lean Six Sigma
Robert Packer Hospital
Pamela Orshaw, RN
[email protected]
QC126: To Ensure 100% Accuracy in
Recording for Services Rendered
Singapore General Hospital
Calvin Liu Chee Piow
[email protected]
25th Annual National Forum on Quality Improvement in Health Care
QC129: Troponin in the Emergency
Department: Maintaining Quality
While Decreasing Turnaround
Time and Cost
The Heart Hospital Baylor
Pamela Tassan
[email protected]
QC130: Using Technology to
Implement Best Practices for Blood
Transfusions
HealthPartners, Regions Hospital
Lynne Preese
[email protected]
QC131: Utilizing Technology to
Reduce Medication Errors in
Chemotherapy Drug Preparation
University of Texas, MD Anderson Cancer
Center
Miguel Lozano
[email protected]
QC132: Variation Reduction and Value
Unit Scales: An Innovative Approach
to Quality and Total Cost Measures
Palo Alto Medical Foundation
Veko Vahamaki DO
[email protected]
QC133: Video Surveillance: Improving
Safety and Quality While Reducing
Expenses
NCH Health Care System
Jordan Mayberry, RN
[email protected]
QC134: Volume to Value: The
Challenges Associated with Negotiating Bundled Payments Utilizing
Harvard’s TDABC Methodology
Connecticut Joint Replacement Institute
Maureen Geary
[email protected]
QC135: Waging the War on Inappropriate Warfarin Use
Franciscan Alliance
Beth Grbavac, RN
[email protected]
QC136: Working Well-TPE
Partnership: Achieving Performance
Excellence and Earning a Regional
Baldrige Award in the Process
Franciscan Alliance
Beth Grbavac, RN
[email protected]
QC137: Would You Like a Lactate?
Boosting Lactate Measurement in the
ED for Early Sepsis Recognition
St. Michael’s Hospital
Melissa McGowan
[email protected]
QC13: You Need a SCD for VTE?
Franciscan Alliance
Beth Grbavac, RN
[email protected]
Improvement
Capability
IC5: A Resident Initiative to Increase
Use of Naltrexone for Alcohol
Use Disorder
San Francisco General Hospital
Shilpa M. Shah, MD
[email protected]
IC6: A Trinity of Engagement Transforms
Care at UPMC Shadyside’s 6 Main
UPMC
Irma D’Antonio, RN
[email protected]
IC7: Addressing Childhood Obesity
in the Primary Care Setting:
Are We Measuring Up?
Texas Tech University Health
Sciences Center
Tracey Page, RN
[email protected]
IC8: Aligning Communication Among
Health Care Professionals
During the Performance of
Fetal Health Surveillance
London Health Sciences Centre
Margaret Belliveau, RN
[email protected]
IC9: Apply Lean to Streamline Breast
Imaging Processes: To Reduce
Patients’ Waiting Time
Singapore General Hospital
Chan Lee Lee
[email protected]
IC10: Building a Better Emergency
Department
Seattle Children’s Hospital
Dawn Cotter, RN
[email protected]
IC11: Building Capacity for Sustained
Improvement in Acuity Adaptable
Critical Care Unit: Focused
Applied Coaching
Geisinger Health System
Tracy Edelstein, RN
[email protected]
IC14: Closing the Gap: Aligning
Education and Process Improvement
in Clinical Practice
Close Care Gap
Kate ONeill, RN
[email protected]
IC15: Committee System
Transformation Using SBAR, a
Standardized Communication Tool
Vancouver Island Health Authority
Shawna Adams
[email protected]
IC16: Cytotoxics: Keeping Staff
and Patients Safe
London Health Sciences Centre
Jennifer Yoon, RN
[email protected]
IC17: Declining Resilience Among
Health Care Workers May Jeopardize
Teamwork and Safety Improvement
Sustainability
Adventist Health
Joanna Bokovoy, RN
[email protected]
IC18: Developing and Sustaining an
Effective Orientation Process
in Health Care
Geisinger Health System
Kelly Cresci
[email protected]
IC19: Dramatic Decrease in Clinic
Verification Time Resulted in
Preventing Workaround and
Improvement of Patient Safety
SEHA
Azhar Talal RPh
[email protected]
IC20: Driving Quality and Service
Improvement Through Physician
Education and Performance
Evaluation
Gundersen Health System
Marilu Bintz, MD
[email protected]
IC21: Effecting Patient Experience
Through eLearning for the Care Team
Remedy Healthcare Consulting
Sheila Richmeier, RN
[email protected]
IC22: Emergency Department: Door to
Provider in Less Than 15 Minutes
Seattle Children’s Hospital
Dawn Cotter, RN
[email protected]
IC23: Enhancing Care Team
Communication
University of Pennsylvania Hospital
Neha Patel, MD
[email protected]
IC24: Ensuring Quality in the
Nurse-Managed Pre-Pre Analytic
Specimen Collection Phase
Sunquest Information Systems
JoAnne Scalise, RN
[email protected]
IC25: Evidence-Based Spiritual
Care Training
London Health Sciences Centre
Jill McTavish
[email protected]
IC36: Is Health Care Really Different?
A Perspective from a Veteran Black Belt
Guthrie Clinic
Jonathan Meigs
[email protected]
IC37: Leadership for Changing
Times: Staff-Led, LeadershipSupported Improvement
St. Joseph’s Health Centre
Julie Ninnis, RN
[email protected]
IC26: Facilitating Easy Disposal of
Oro-Pharyngo-Tracheal
Suctioning Requisites
Singapore General Hospital
Sa’adiah Binte Arsad RN
[email protected]
IC38: Making Metrics Meaningful:
“I Impact the Organization’s Goals”
BIDMC
Michelle Sheppard, RN
[email protected]
IC27: From Volume to Value:
Academia Meets the Community
Columbia HeartSource
Paul Kurlansky, MD
[email protected]
IC28: High Reliability Organizations
Require Dream Teams
Courtemanche & Associates
Nancy McLean, RN
[email protected]
IC29: HIV Screening: Using QI to
Enhance Teamwork in a VA
Medical Home Clinic
Louis Stokes VA Medical Center
Moshe Ornstein, MD
[email protected]
IC30: Holistic Value Stream Mapping
Using Enterprise Architecture
Methodologies
Guthrie Health System
Dennis Robi
[email protected]
IC31: Implementation of an In-House
Certification Program for New
Operating Room Registered Nurses
London Health Sciences Centre
Sandra Harwood, RN
[email protected]
IC32: Improving Nursing Compliance
of Pain Reassessment (60 minutes of
Opioid Administration); Maternity
and Medical/Surgical Units
Intermountain Health Care
Mary Zeigle
[email protected]
IC33: Improving Outpatient Cardiac
Rehabilitation Program Referrals
Post Myocardial Infarction
The Heart Hospital Baylor Plano
Kristi Verschelden, RN
[email protected]
IC34: Improving Quality Improvement
Residency Education and Provider
Performance Through a Shared
Online Experience
Duke University Medical Center
Jonathan Bae, MD
[email protected]
IC35: Introduction of a Structured
Orientation Programme for
Registered Nurses in a Community
Hospital in Singapore
Bright Vision Hospital, Singapore
Salimah Binte Mohd Ayoob, RN
[email protected]
STORYBOARDS
IC1: A Campaign to Raise Awareness
of Health Care Disparities
Henry Ford Health System
Megan Brady
[email protected]
IC2: A Foundation in Quality
Improvement
North Bristol NHS Trust
Benjamin Plumb
[email protected]
IC3: A Model for Improving the
Outpatient Experience
University of Texas, MD Anderson
Cancer Center
Sue Ferguson, RN
[email protected]
IC4: A Nationwide Clinical Quality
Improvement Pilot: Improving
Screening for Chlamydia
Planned Parenthood Federation
of America
Mytri P. Singh
[email protected]
IC12: Centralized Clinical Education
Model at London Health Sciences
to Achieve Quality Outcomes
London Health Sciences Centre
Vanessa Burkoski, RN,, PhD
[email protected]
IC13: Change Agent Fellowship
Contra Costa Regional Medical Center
Amber Owens
[email protected]
IC39: Making the Case for Change:
Developing an Integrated,
Territory-Wide Chronic Disease
Management Strategy
Canadian Foundation for Health Care
Improvement
Jennifer Verma
[email protected]
IC40: MD Anderson’s Quality
Improvement Curriculum
University of Texas, MD Anderson Cancer
Center
Robert Joyce
[email protected]
IC41: Mentoring Effective
Implementation of the SLMTA
Program at the Country Level for
Vietnam and Cambodia
Global Health Consulting BCM
Barbara McKinney, MD
[email protected]
IC42: Meta-Management II:
Management for Management Using
Checklist Based on IS0 9001
Aso Iizuka Hospital
Hiromi Ando, MD, PhD
[email protected]
IC43: Mobile Technology: Facilitating
Patient Care and Increasing
Productivity
London Health Sciences Centre
Minakshi Sharma
[email protected]
IC44: Nurse-Led Fast Track in
Emergency Department
Southern District Health Board
Leanne Samuel, RN
[email protected]
IC45: Optimizing AECOPD Care
Through Collaboration, Innovation,
and Process: A Regional Perspective
from British Columbia, Canada
South Okanagan Similkameen Division
of Family Practice
Shannon Walker, MD
[email protected]
IC46: Our Journey Towards Quality
Improvement and Implementation
Region Zealand Hospital Naestved,
Slagelse and Ringsted
Helmer Buchardt Pedersen, MD
[email protected]
IC47: Performance and Quality
Improvement Using the DMADV
Methodolgy
Health Care Improvement Providers LLC
Sean Anzuoni
Sean@Health Carepqs.com
Which storyboard did you enjoy? Tweet it using #IHI25Forum
51
STORYBOARDs
Storyboard Reception
Tuesday, December 10, 4:30 PM – 6:30 PM, Palms Ballroom
During this reception, presenters will be standing by their boards to answer questions.
IC67: Women’s Clinic Laboratory
Sample Collection Process Redesign
to Reduce Collection Errors
Kaiser Permanente Santa Clara
Medical Center
Francisco Rodriguez
[email protected]
Leadership
IC48: ProvenCare® Lumbar Spine: A
Mesosystem Approach to Improving
Outcomes
Geisinger Health System
Kelley Morrison, RN
[email protected]
IC49: Radiography Complete Patient
Histories to Improve Diagnosis
Cincinnati Children’s Hospital Medical
Center
Wendy Bankes
[email protected]
IC50: Redesigning the Emergency
Department to Improve Door-to-Doc
Time and Patient Satisfaction
Intensimed
Amilcar Mocelin, MD
[email protected]
IC51: Reducing Arthroscopes’ Repairs
in Major Operating Theatre and
Ambulatory Surgery Centre in
Singapore General Hopsital
Singapore General Hospital
Seah Xueli Eileen
[email protected]
IC52: Reducing the Frequency of
Replacing Damaged Case Notes Folder
Singapore General Hospital
Tan Lee Eng Priscilla
[email protected]
IC53: Strategies to Implement
Complimentary Bedside
Safety Initiatives Using
Kotter’s Change Model
University of Wisconsin Hospital
and Clinics
Anne Mork, RN
[email protected]
IC54: Streamlining Health Metric Collection to Strengthen Project Monitoring and Evaluation in an NGO Setting
Thames Valley and Wessex NHS
Leadership Academy
Adam Barnett
[email protected]
IC55: Student Experience: Systems
Design for Non-Medical Student
Placements
London Health Sciences Centre
Kelly Ainge
[email protected]
IC56: Systematic Approach to Assess
Sink Availability and Accessibility
in a Multi-Hospital System
Orlando Health
Scott Brown, RN
[email protected]
IC57: The Cervical Smear Program in
a Low Income and Developing
Population: A South African
Perspective
Improving Global Health
Ann-Marie Streeton MB ChB
[email protected]
52
IC58: The Culture Connection:
Combining a Culture of Safety & Just
Culture to Create High Reliability
Courtemanche & Associates
Darlene Christiansen, RN
[email protected]
IC59: The Effect of Using the Lean
Tools in the Emergency Department of
a Saudi Hospital
The Royal Commission Health Services
Program - Yanbu Industrial City
Alber Paules, MB ChB
[email protected]
IC60: The Geisinger Quality Institute:
Improving Dischagre Times Through
a Collaborative Microsystem
Improvement Approach
Geisinger Wyoming Valley Medical
Center
Daniel Amorino
[email protected]
IC61: Triad Models for Quality:
The Shape of Things to Come
Orlando Health
Anne Peach, RN
[email protected]
IC62: Two New Hospitals: A Lean Six
Sigma Approach to Transition
Corning Hospital
Megan Hawkins, RN
[email protected]
IC63: UC Davis Health System Journey
to Patient Centered Medical Home to
Improve the Patient Experience
University of California Medical Center
Angela Gandolfo
[email protected]
IC64: Using the Patient Safety
Education Program to Improve
Leadership Engagement and
Execution of QI Processes
Institute for Public Health and
Medicine, Northwestern University
Mitesh B. Rao, MD
[email protected]
IC65: Using Multidisciplinary
Collaborative Models to
Eliminate Central Line Associated
Bloodstream Infections in Non-ICU
Medical-Surgical Wards
Cedars-Sinai Medical Center
Claude Killu, MD
[email protected]
IC66: Using Six Sigma to
Improve Safety in the Patient
Surgical Experience
North Shore Long Island Jewish –
Huntington Hospital
Corazon R. Paraso, RN
[email protected]
L1: First Things First: What is the
Current Reality?
Carolinas Health Care System
Colleen Hole, RN
Colleen.Hole@carolinasHealth Care.org
L2: Medical Control Protocols as a
Foundation for Quality Management
Alberta Health Services (Emergency
Medical Services)
Glenn McRae, RN
[email protected]
L3: Prioritizing Cancer Quality
Measures
University of Texas MD Anderson
Cancer Center
Lisa Kidin, RN
[email protected]
L4: Safety Programme Inducing
Organisational Culture Change
Lillebaelt Hospital
Dorthe Cruger, MD, PhD
[email protected]
L5: Using Cross-Institutional Learning
to Reduce Surgical Site Infection
Rates in Pennsylvania
York Hospital
Vanita Ahuja, MD
[email protected]
Patient Safety
PS1: A Community Hospital’s
Approach to Infection Prevention
Flagler Hospital
William Hepler, RN
[email protected]
PS2: A Multidisciplinary Approach
to Improve Anticoagulation Safety:
Improving Patient Re-Engagement
and Adherence to Care Plan
Beth Israel Deaconess Medical Center
Diane M. Brockmeyer, MD
[email protected]
PS3: A New Collaborative Improvement Model: Leading to Success in
California Hospitals
California Hospital Association/
Hospital Quality Institute
Sandra Trotter
[email protected]
PS4: Addressing Critical Lab Values
After Regular Practice Hours:
Improving Communication and Care
Woodhull Medical and Mental
Health Center
Jonah Green, MD
[email protected]
PS5: Adverse Drug Event Reduction
Through Guardrail Infusion Pump
Auditing and Just-In-Time Education
Children’s National Medical Center
Valere Lemon, RN
[email protected]
25th Annual National Forum on Quality Improvement in Health Care
PS6: Air Transport of Large Patients:
Guidelines to Keep Patients and
Staff Safe
University of Michigan Health System
Kathleen Lanava
[email protected]
PS7: Alert Signs Prior to Death in
Ward-Patients Recovering from
Postoperative Orthopedic Surgery
Instituto Nacional de Traumatologia e
Ortopedia
Luciana Carvalho
[email protected]
PS8: Ambulatory Medication Reconciliation: A Collaborative Approach
Brigham and Women’s Hospital
Caroline Keogh, RN
[email protected]
PS9: Assisting with the Assist Device:
Implementation of a Training Program
on Ventricular Assist Devices
London Health Sciences Centre
Rachelle Mccready, RN
[email protected]
PS10: Auditory Responses to
Everyday Sounds in Patients with
Chronic Pain
Simon Fraser University
Mark Nazemi
[email protected]
PS11: Checklists and Quality
Outcomes Correlation Versus
Causation—One Year Later
Geisinger Health System
A. Joseph Layon, MD
[email protected]
PS12: Communication Between the
Emergency Department and
Long-Term Care Facilities:
Improving Transitions in Care
London Health Sciences Centre
Leon Petruniak, RN
[email protected]
PS13: Comparison of Normal Saline
and Heparinised Saline Flush for Arterial Catheter in Adult Patients
National Heart Centre Singapore
Jasmine Lee, RN
[email protected]
PS14: Construction of the Patient
Safety Policy of the Sao Camilo
Hospital
Rede de Hospitais Sao Camilo
Daniela Akemi Costa
[email protected]
PS15: Data Analysis Drive Project
Prioritization for Improved Patient Flow
Health Sciences North
Shannon Kenrick-Rochon, RN
[email protected]
PS16: Decreasing MRSA Colonization
in the Intensive Care Nursery
Hospital of the University of
Pennsylvania
Michael Posencheg, MD
[email protected]
PS17: Delirium Bundle Implementation:
Report of a Medical-Surgical ICU
Sao Camilo
Leonardo Brauer, MD
[email protected]
PS18: Destroying the State of Sepsis
MedStar Washington Hospital Center
Sally Gutierrez, RN
[email protected]
PS20: Do Mock Drills Prepare Health
Care Workers (HCWs) for Actual
Medical Emergencies?
The Aga Khan University Hospital
Rozina Roshan Essani, RN
[email protected]
PS21: Driving a Microsystem
Improvement Portfolio
The Children’s Hospital of
Philadelphia
Debra Geiger
[email protected]
PS22: Drug Recall Notification: A
Comprehensive Program in
Ambulatory Care
North Shore-LIJ Health System
Leonard Langino RPh
[email protected]
PS23: Early Mobility of Critically Ill
Patients in a Community Hospital
Mayo Clinic Health System - Mankato
Erin Brokl, RN
[email protected]
PS24: Effects of Rapid Response
Team Activation Training in a General
Hospital
Sao Camilo
Camila Paiva de Vasconcelos, MD
[email protected]
PS25: Electronic Surgical Safety
Checklist Ensures Adoption
LiveData, Inc.
Jeff Robbins
[email protected]
PS26: eMEWS Triggers Appropriate
Monitoring & Care Escalation
North Shore-LIJ Health System
Kevin Bock, MD
[email protected]
PS27: Encouraging Reporting Through
Visible Improvements
Juronghealth Services
Andie Zhang Zhixuan
[email protected]
PS28: Enhancing Quality and Safety
through Walkabouts at Health
Sciences North
Health Sciences North
Shannon Kenrick-Rochon, RN
[email protected]
PS29: Falls Which Led to Lesions in
Orthopedic Patients Admitted to
Hospital in Rio de Janeiro
Instituto Nacional de Traumatologia e
Ortopedia
Luciana Carvalho
[email protected]
PS30: Fighting CLABSI:
An Interdisiplinary Approach for
Best Practice Outcomes
Cancer Treatment Centers of America
Deborah Baldassarre, RN
[email protected]
PS55: Incorporating IOM/QSEN
Competencies into a Nurse
Residency Program
Versant Holdings, LLC
Larissa Africa, RN
[email protected]
PS32: Foley Catheter Removal
North Shore Medical Center
Michael D. Medlock, MD
[email protected]
PS33: Gaps in Cardio Pulmonary
Resuscitation (CPR) Documentation:
A Step Towards Reducing Risk of
Legal Implications
The Aga Khan University Hospital
Rozina Roshan Essani, RN
[email protected]
PS44: Improvement in Hand Hygiene
Compliance: An Institution Wide
Initiative for Patient Safety
The Aga Khan University Hospital
Suneina Musani
[email protected]
PS45: Improving Care of High-Risk
Inpatients: A Pilot Study
North Shore Long Island Jewish
Health System
Sienna Moran, MD
[email protected]
PS56: Increasing the Percentage
of Patients Post Laparotomies
for Non-Malignant Disorders
Discharged on Fourth PostOperative Day
Singapore General Hospital
Punasundri D/O Thangaraju
[email protected]
PS34: “Growing is in Progress:
Reduction in Elective Deliveries Less
than 39 Weeks”
Sarasota Memorial Hospital
Renee Maietta
[email protected]
PS46: Improving Communication and
Learning Between Hospital Health
Team and the Inpatient
Clinica San Felipe SA
Ernesto Aspillaga, MD
[email protected]
PS35: Guidewires Unintentionally
Retained During Central Venous
Catheterization
UHC
Tammy Williams, RN
[email protected]
PS47: Improving Current Leg Elevator
(Braun Frame)
Singapore General Hospital
Rosida Binte Jantan
[email protected]
PS48: Improving Hospital Acquired
Pressure Ulcers (HAPU) Through
Monitoring and Management (A
Initiative)
The Aga Khan University Hospital
Yasmin Vellani, RN
[email protected]
PS36: Happie Lappie!
Singapore General Hospital
Shahidah Bte Roslan
[email protected]
PS37: High Risk Neonatal Transitional
Care Model for Quality Improvement
London Health Sciences Centre
Sheeva Woznuk, RN
[email protected]
PS38: How Low is Too Low? The
Overtreatment of Diabetes
Mellitus in the Elderly
Louis Stokes VA Medical
Center/Cleveland Clinic Foundation
Tania Jaber, MD
[email protected]
PS39: I-PASS: Creation, Implementation, and Dissemination of a Bundled
Handoff Intervention
University of Toronto
Trey Coffey
[email protected]
PS40: Implementation of the Sepsis
Six Pathway for Severe Sepsis
Gloucestershire Hospital NHS Foundation
Trust
Andrew Seaton, RN
[email protected]
PS41: Implementing a Purposeful
Pause at Hospital Discharge
York Hospital
Dawn Becker, RN
[email protected]
PS42: Implementing and Sustaining
an Effective VAP Prevention Bundle
Nationwide Children’s Hospital
Randall Frost
[email protected]
Improved Compliance with Heart
PS49: Improving Medication
Administration Safety in a
Community Hospital Using
Lean Methodology
Headwaters Health Care Centre
Sandy Critchley
[email protected]
PS57: Integration of EvidenceBased Health Care and Quality
Improvement Strategies in Falls
Reduction in NUH, Singapore
National University Hospital
Siti Zubaidah Bte Mordiffi
[email protected]
PS58: It Takes a Team: Failure to
Involve PT/OT and Readmission Risk
University of Minnesota Medical Center
Neal Boeder, MD
[email protected]
PS59: “It’s Not A Hard Pill to Swallow”:
Implementing a Bedside Swallowing
Screen for Acute-Stroke Care
London Health Sciences Centre
Lynda Ryall-Henke, RN
[email protected]
PS60: Knock Out Fall Incidence
Singapore General Hospital
Nur Jannah Zhong Yarui, RN
[email protected]
PS61: Less is Morphine: Enhancing by
Decreasing Opioid Related Incidents
Sunnybrook Health Sciences Centre
Trevor Hall, RN
[email protected]
PS50: Improving Nurses’ Knowledge
in Management of Patients
with Pressure Ulcer(s) in Ward
64 by 30%
Singapore General Hospital
Yan Na, RN
[email protected]
PS62: Long-Term Improvement of
Central Line Associated Blood Stream
Infections at Bumrungrad
International Hospital Year
2002-2012
Bumrungrad International hospital
Junya Charayopas, RN
[email protected]
PS51: Improving Patient Safety by
Implementation of Pre-Procedure Time
Out Verification at Endoscopy Suite
The Aga Khan University Hospital
Sumaira Sachwani, RN
[email protected]
PS63: Making Sure Safety Culture
Assessment Benefits
Improvement Efforts
Det Norske Veritas (DNV)
Tita Alissa Listyowardojo, PhD
[email protected]
PS52: Improving Quality of
Afghanistan Primary Health Care
Through Standard Based Management
and Recognition
Mohammad Basir Farid
[email protected]
PS64: Med Rec or Med Wreck:
Making Medication Reconciliation
Work in the Cardiac Surgery Population
London Health Sciences Centre
Anne McVety, RN
[email protected]
PS53: Improving Surgical Site
Infections in the Colon Surgery
Population
North Shore Medical Center
Ninamarie Qualtieri, RN, RN
[email protected]
PS65: Mislabeled Specimens: One
Institution’s Story
The Hospital of Central Connecticut
Kathy Scrittorale
[email protected]
PS65: Navigating the Challenges
of Patient Flow and Boarding in
Hospitals
The Joint Commission
Patricia Adamski, RN
[email protected]
PS54: Including Patients and Families
as Part of Team Approach to Fall
Prevention
Brigham and Women’s Hospital
Escel Stanghellini, RN
[email protected]
STORYBOARDS
PS19: Developing & Enhancing
Utilization of Written Discharge
Instructions (DIs): An Initiative
The Aga Khan University Hospital
Rozina Roshan Essani, RN
[email protected]
PS43: Failure Quality Indicators
at a Brazilian Non-Teaching
Private Hospital
Hospital Israelita Albert Einstein
Alessandra Correa, RN, PhD
[email protected]
PS31: First National Survey of
Patient-Controlled Analgesia
Practices
Physician-Patient Alliance for
Health & Safety
Michael Wong
[email protected]
Which storyboard did you enjoy? Tweet it using #IHI25Forum
53
STORYBOARDs
Storyboard Reception
Tuesday, December 10, 4:30 PM – 6:30 PM, Palms Ballroom
During this reception, presenters will be standing by their boards to answer questions.
PS67: New Hospital Activation Using
Human Patient Mannequin Simulation
to Evaluate Patient Workflow and Safety
VHA
Yasuharu Okuda, MD
[email protected]
PS68: Nursing Survey Revealed Novel
Strategy Assists in Adherence to
Best Practices of CVC Dressing
Management
Cookeville Regional Medical Center
Jamie Deneau
[email protected]
PS77:Pilot Study to Assess Risk for
Aspiration of Enteral Contrast for
Diagnostic Tests
Orlando Health
Thomas Kelley, MD
[email protected]
PS78: Planning the Education of
Patients and Relatives at INTO: A
Strategy for Full Attention
Instituto Nacional de Traumatologia e
Ortopedia
Luciana Carvalho, RN
[email protected]
PS69: Offensive Talks, Attitudes
Affects on Older People
The American Academy on
Communication in Health Care
Sofica Bistriceanu, MD, PhD
[email protected]
PS70: One Size Fits All? The
Improvement Sciences Approach
North Shore Long Island Jewish – Lake
Success
Nancy Riebling
[email protected]
PS79: Post Orientation Mini Master
Rotation (POMMR) There is “Light at
the End of the Tunnel”
London Health Sciences Centre
Karen Burnett, RN
[email protected]
PS80: Pressure Ulcer Improvement
Process
North Shore Medical Center
Greg Conklin, RN
[email protected]
PS71: Patient Safety First…
A California Partnership for Health
National Health Foundation
Heidi Fischer
[email protected]
PS72: Pediatric Skin Injury Reduction
in the Operating Room
Nationwide Children’s Hospital
Mike Fetzer
[email protected]
PS73: Perception & Barriers
Regarding Self-Signed and Relative
Signed Informed Consent (IC): A
Comparative Study
The Aga Khan University Hospital
Rozina Roshan Essani, RN
[email protected]
PS74: Performance Improvement
Through Simulation Education
Medical Simulation Corporation
Arthur Childs, MD
[email protected]
PS75: Permanent Kaiser: Helping the
Identification of Environmental
Risks and Hospital Safety at INTO
Instituto Nacional de Traumatologia e
Ortopedia
Luciana Carvalho
[email protected]
PS76: Pharmacist Medication
Reconciliation Involving CHF Patients
North Shore Medical Center
Andrea Barayuga-MacLean,
PharmD, RPh
[email protected]
54
PS81: Pressured Over Pressure
Ulcers?: Eliminating Hospital
Acquired Pressure Ulcers in Saudi
Patients at NGHA AL Ahsa
National Guard Health Affairs
Eastern Region
Jamellah Gimenez, RN
[email protected]
PS82: Preventing Non-Ventilator
Hospital Acquired Pneumonia with an
Oral Care Intervention
Sutter Medical Center, Sacramento
Barbara Quinn, RN
[email protected]
PS83: Quality Improvement and
(QIPS) Initiatives at Division of
Nursing Services: An Overview
The Aga Khan University Hospital
Rozina Roshan Essani, RN
[email protected]
PS84: Re-Engineering Outpatient
Parental Antimicrobial Therapy
(OPAT): A Process Change for Better
andSafe Care
Mayo Clinic
Deborah C. Beck, RN
[email protected]
PS85: Reduce Insulin Related
Adverse Drug Events (ADE) Using
Quality Improvement (QI) Initiatives
Nationwide Children’s Hospital
Jenna Merandi PharmD, RPh
[email protected]
PS86: Reducing Drug Administration
Interruptions: An Intervention Study
University of Verona
Francesca Moretti
[email protected]
PS87: Reducing Incidence of
Retained Surgical Instruments in
York Hospital’s Operating Room
WellSpan Health,York Hospital
Virginia Wesner
[email protected]
PS88: Reducing Pain and Discomfort
for Patients with Scrotal Swelling
Singapore General Hospital
Lee Teng Teng
[email protected]
PS89: Reducing Radiation Dose in
Pediatric Appendicitis CT
North Shore Medical Center
John Murray, MD
[email protected]
PS90: Reducing Retained Surgical
Sponges Using Sponge ACCOUNTing
Hospital Sisters Health System
Darren Barnes, RN
[email protected]
PS91: Reducing Sedation for Vented
ICU Patients
North Shore Medical Center
Lee Anne Fredericks, RN
[email protected]
PS92: Reducing Transmission of
Antibiotic-Resistant Organisms
(AROs) Through Daily Antiseptic
Patient Bathing
Rouge Valley Health System
Paula Raggiunti, RN
[email protected]
PS93: Registered Nurses’ Knowledge
on the Administration of Biologic
Drugs: An Audit Survey
Singapore General Hospital
Nurshifa Binte Shaik Hussain
[email protected]
PS94: Residents as Drivers of Outpatient Practice Improvement: A Unique
Solution to Promoting High Quality Care
Beth Israel Deaconess Medical Center
Joshua Allen-Dicker, MD
[email protected]
PS95: Respect for People:
Shining a Light in a Dark Place
Spectrum Health
Gail Greco-Bieri
[email protected]
PS96: Right Patient – Right Care:
Preventing Patient Identification
Errors in Medical Records
Aga Khan University Hospital
Saba Dossani, RN
[email protected]
PS97: Safely Speaking: Improving the
Culture of Through Storytelling
Medical University of South Carolina
Chris Rees
[email protected]
PS98: Safety Culture and Lean
Daily Management
Tenet Healthcare Corporation
Patrick Smith, MD
[email protected]
PS99: Safety: Every Patient, Every
Time: A Leading Catholic Health
System’s Journey to Safety Culture
Improvement
CHE Trinity Health
Theresa Aldini, RN
[email protected]
25th Annual National Forum on Quality Improvement in Health Care
PS100: Sign of the Times—Making
Cytotoxic Safety Visible
London Health Sciences Centre
Monica Kaszycki, RN
[email protected]
PS101: SOS: Save Our Skin—A
Pediatric Pressure Ulcer Prevention
Program
Ann & Robert H. Lurie Children’s Hospital
of Chicago
Ann & Robert H. Lurie
[email protected]
PS102: Spreading Best Practice for
Prevention of Central Line
Associated Blood Stream Infections
Yale-New Haven Hospital
Carrie Guttman, RN
[email protected]
PS103: Standardizing Perioperative
Hand-Off Communication
Baylor Medical Center At Irving
Courtney Sheward, RN
[email protected]
PS104: Starting the Week off Right:
Monday Morning Huddle to
Improve Patient Safety
Windsor Regional Hospital
Corry O’Neil, RN
[email protected]
PS105: Surgery Safety Checklist in
High Risk/Volume OR
University of Texas, MD Anderson Cancer
Center
Charles F. Levenback, MD
[email protected]
PS106: Survey on Culture—
Comparing Years
Rede de Hospitais Sao Camilo
Daniela Akemi Costa
[email protected]
PS107: Tackling Sepsis Through a
Nurse Driven Approach
UPMC Shadyside
Denise Stromoski, RN
[email protected]
PS108: The Brazilian Sign Language
(LIBRAS) DEAF—and its Application
at INTO: A Case Report
Instituto Nacional de Traumatologia e
Ortopedia
Luciana Carvalho
[email protected]
PS109: The Highs and Lows of Resuscitation Journey in National University
Hospital (NUH)
National University Hospital
Bhuvaneshwari Mohan Kumar
[email protected]
PS110: The Northwest Dialysis
Bloodstream Infection Prevention
Collaborative
Oregon Commission
Melissa Parkerton
[email protected]
PS111: TransCu O2 Wound Healing in
Long Term Care
Responsive Management Inc.
Debbie Green
[email protected]
Person- and
Family-Centered Care
PF1: A Primary Care Approach
to Tobacco Education and Smoking
Cessation in Samlout, Cambodia
Oxford Health NHS FT
Shoba Subramanian
[email protected]
PF2: A Scalable Advance Care
Planning Initiative
Twin Cities Medical Society/Honoring
Choices Minnesota
Sue Schettle
[email protected]
PF3: Activation in Vulnerable Patients
with Chronic Respiratory Disease
(COPD/Asthma)
Fletcher Allen Health Care/OneCare
Vermont
Vicki Loner, RN
[email protected]
PF4: Aligning Goals of Care
VA Palo Alto Health Care System
Ruchir Shah, MD
[email protected]
PF5: An Automated Wellbeing and
Service Follow-Up Solution That
Facilitates ED Case Management
Edward Hospital
Tom Scaletta, MD
[email protected]
PF6: An Interprofessional Approach
to Behavioral Emergencies at the
University of Virginia
University of Virginia Health System
Gabrielle Marzani-Nissen, MD
[email protected]
PF7: An Online Platform for Meaningful Engagement with Patients and
Communities: IdeaExchange.sw.org
Scott & White Health Care
Angie Hochhalter, PhD
[email protected]
PF8: Asynchronous Web Visits for
Chronic Conditions: Implementation in
a Busy Primary Care Practice
Partners Health Care
Ronald Dixon, MD
[email protected]
PF9: Building and Spreading a Family
Caregiver Education Program
Henry Ford Health System
Sheila Daley, RN
[email protected]
PF10: Embedding Shared Decision
Making in Early Breast Cancer Care
Cardiff and Vale University Health Board
Helen McGarrigle, RN
[email protected]
PF11: Enhancing the Patient
Experience in an Outpatient
Cancer Center
University of Texas, MD Anderson
Cancer Center
Jeremy Meade
[email protected]
PF12: Enhancing the Patient Voice
at St. Joseph’s Health Care Hamilton
St. Joseph’s Health Care Hamilton
Michelle Joyner
[email protected]
PF13: Get a Grip!
Central Manchester University
Hospitals NHS Foundation Trust
Jane Mottershead, RN
[email protected]
PF14: Improve Patient Experience
and Reduce Readmissions with Better
Discharge Communication
Cullman Regional Medical Center
Cheryl Bailey
[email protected]
PF15: Improving Communication for
Patient Engagement
Rede de Hospitais Sao Camilo
Daniela Akemi Costa
[email protected]
PF16: Improving the Patient
Experience Through Better Cancer
Symptom Management: A System
Wide Improvement Collaborative
Cancer Care Ontario
Reena Tabing
[email protected]
PF17: LEAN On Me: Practical
Strategies for Improving Patient
Satisfaction Through Improved
Emotional Support
Windsor Regional Hospital
Ralph Nicoletti
[email protected]
PF22: Managing Referrals for
Psychological Services for Patients
on the Behavior Medicine Service
Waiting List
London Health Sciences Centre
Felicia Otchet, PhD
[email protected]
PF35: Validating the Patient Experience with Race, Language and
Ethnicity Collection
University of California Medical Center
Angela Gandolfo
[email protected]
PF24: Patient Engagement and
Population Health: Leveraging
Technology to Improve Preventive
Screening Rates
Emmi Solutions
Jordan Dolin
[email protected]
PF25: Patient Navigation—Oncology
Rehabilitation
Samaritan Hospital – St. Peterâ™s
Health Partners
Sabrina Mosseau, RN
[email protected]
PF36: Watch and Wait Without
Wonder: Improving Communication
for Family Members in an
Outpatient Surgical Setting
Mayo Clinic
Pamela Maxson
[email protected]
PF26: Patients as Change Agents:
A Model for Engagement from
Humboldt County, CA
Aligning Forces Humboldt at the
California Center for Rural Policy
Jessica Osborne-Stafsnes
[email protected]
PF27: Personalization in Health Care:
Lessons from Industry
Western University
Karin Schnarr
[email protected]
PF28: Pitfalls in the Informed Consent
Process: Achieving “PatientCentricity” for Informed Consent
Datix
Daniel Cohen, MD
[email protected]
PF18: Legal & Health Literacy Issues
During Registration
Novant Health
Thomas Bauer
[email protected]
PF19: Leveraging Patient-Specific
Knowledge as Part of the LHSC
Shared Governance Model
London Health Sciences Centre
Vanessa Burkoski, RN,, PhD
[email protected]
PF20: Leveraging Technology to
Improve Patient Engagement
Department of Veterans Affairs
Gerald Showecker
[email protected]
PF21: Lung Biopsy—Reduction in
Procedure Start Times
North Shore Medical Center
Miriam Neuman, MD
[email protected]
PF23: Northern Parterns in Care—
Improving Access to Quality Care in
Rural and Remote Communities
University of Northern British Columbia
Tammy Klassen-Ross
[email protected]
PF29: Preventing Admissions &
Readmissions: Providing Health Care
Outcomes not Health Care Services
Datix
Daniel Cohen, MD
[email protected]
PF30: Quality of Life in Patients with
Heart Failure Measured by the Kansas
City Cardiomyopathy Questionnaire
Monmouth Medical Center
Sharon Holden
[email protected]
PF31: Reduce Time Taken for Discharged Inpatient to Receive Final Bill
JurongHealth
Clay Kian Loong Goh
[email protected]
PF32: Team Care for Chronic Disease
Patients: Using Lay “Care Guides”
Allina Health System
Kim Radel
[email protected]
PF33: The Patient Structured Day
London Health Sciences Centre
Elizabeth Runciman, RN
[email protected]
PF34: Univeristy of Florida Health
Physicians Patient Access Center
Default User Profile Organization
Kelly Kerr
[email protected]
Triple Aim for
Populations
TA1: 5 Feet in 5 Seconds:
An Application of Lean Visual
Management
BIDMC
Michelle Sheppard, RN
[email protected]
STORYBOARDS
PS112: Understanding the Value of
Library and Information Services
in Patient Care
London Health Sciences Centre
Karla Van Kessel
[email protected]
TA2: A Collaborative Outreach
Initiative to Improve Colorectal
Cancer Screening
Beth Israel Deaconess Medical Center
Scot B. Sternberg
[email protected]
TA3: ACMS Stable Patient Extended
INR Protocol as a Model for
Implementing Clinical Guidelines
Beth Israel Deaconess Medical Center
Jennifer E Mackey, PharmD
[email protected]
TA4: Analysis of No Shows Among
Allergic Rhinitis Patients at the Khoo
Teck Puat Hospital
Khoo Teck Puat Hospital
Alex Mathews RPh
[email protected]
TA5: Boston to Orlando: IHI’s Annual
Walking Challenge
Institute for Healthcare Improvement
Kelcey Heman
[email protected]
TA6: Breaking Traditions: Integrating
Triage and Fast Track to Improve
Patient Experience in the Emergency
Department
MidState Medical Center
Megan Heidenis, RN
[email protected]
TA7: Change by Design: A New
Paradigm for Primary Care
Mayo Clinic
Douglas Wood, MD
[email protected]
TA8: CMS Requirements for Cancer
Reporting
University of Texas, MD Anderson
Cancer Center
Lisa Kidin, RN
[email protected]
TA9: Creating a Diabetes Group Visit
For Brazilian Diabetic Patients
Cambridge Health Alliance
Monica Demasi, MD
[email protected]
Which storyboard did you enjoy? Tweet it using #IHI25Forum
55
STORYBOARDs
Storyboard Reception
Tuesday, December 10, 4:30 PM – 6:30 PM, Palms Ballroom
During this reception, presenters will be standing by their boards to answer questions.
TA10: Decreased Surgical Ligation
of the Patent Ductus Arteriosus
Following Implementation of
Conservative Clinical Guidelines
Nationwide Children’s Hospital
James Dail
[email protected]
TA11: Driving Quality Initiatives to
Improve the Life of Every Person with
Kidney Disease
Ontario Renal Network
Graham Woodward
Graham.Woodward@renalnetwork.
on.ca
TA12: Early Years Collaborative in
Scotland: The Best Place in the
World to Grow Up!
Scottish Government
Rosamund Gray, RN
[email protected]
TA13: Effects of the Critical Care
Outreach Team on Bone Marrow
Transplantation Ward Survival
Sao Camilo
Claudia Jorge, MD
[email protected]
TA14: Emergency Medical Pediatric
Program (EMP): Timely Access
to Specialized Paediatric Care
Windsor Regional Hospital
Kelly Bartnik, RN
[email protected]
TA15: Frail Elderly Predictive Care
Model
Mercy Hospital
Linda Horton, RN
[email protected]
TA16: Healthy Heart—Healthy Mind
London Health Sciences Centre
Kamini Vasudev, MD
[email protected]
TA17: Implementation of a Critical
Care Outreach Team on Bone Marrow
Transplantation Ward
Sao Camilo
Claudia Jorge, MD
[email protected]
TA18: Improving HEDIS Quality
Performance Through Cost-Effective
Technology and Enhanced Patient
Engagement
Kaiser Permanente
Karen Clark
[email protected]
TA19: Improving Patient Access and
Experience Through Deployment
of Advanced Access Scheduling
MultiCare Health System
Ashley Keays DO
[email protected]
56
TA20: Improving Performance in
Practice (IPIP) Advances
State-Based Primary Care
American Board of Medical Specialties
Sigita Wolfe
[email protected]
TA21: Increased Screening for
Proteinuria in Chronic Kidney Disease
Using Education and Reminders
Louis Stokes VA Medical Center
Jeffrey Beamish, MD, PhD
[email protected]
TA22: It’s COOL To Be COOL
Methodist West Houston Hospital
Marcia Ozdenvar
[email protected]
TA23: Jump Start Your Heart: A New
Cardiac Program
Methodist West Houston Hospital
Laura Espinosa, RN, PhD
[email protected]
TA24: Optimizing Value Streams for
Breast Cancer Patients to
Receive Supportive Services
Using Lean Methodology
University of North Carolina (UNC)
Health System
Kinley Taylor
[email protected]
TA25: Pneumonia Antibiotic Guidelines Variations in Oncology
University of Texas, MD Anderson
Cancer Center
Lisa Kidin, RN
[email protected]
TA26: Primary Care Integration
Project and Evaluation
University Health Network
Kaitlin Pattrick
[email protected]
TA27: Reducing Heart Failure
Readmissions: The CT Experience
John Dempsey Hospital
Wendy Martinson, RN
[email protected]
TA30: Simplifying Simple Appendicitis: Same Day Discharge after
Appendectomy
Nationwide Children’s Hospital
Kelli Kurtovic
[email protected]
TA31: Staff Experience and Healthy
Work Environment (HWE): A Nursing
Resource Team (NRT) Perspective
Western University
Lisa Ducharme
[email protected]
TA32: Surveying the Potential Needs
of Patients Attending Psychological
Services in a New Clinical Area
London Health Sciences Centre
Felicia Otchet
[email protected]
TA33: The Impact on Patients of
Psychological Services Moving
to a New Clinical Area
London Health Sciences Centre
Andrea Lazosky, PhD
[email protected]
TA34: The Nurse Practitioner Role in
a Comprehensive Pain Management
Program
London Health Sciences Centre
Charlotte McCallum, RN
[email protected]
TA35: The Triple Aim and Outreach to
Long-term Care Patients
Mayo Clinic
Dawn Francis
[email protected]
TA36: The Underreported Pre-Diabetic
Patient’s Identifying Patients
At-Risk for Diabetes In Order to
Improve Outcomes
Esse Health
Carla Beckerle, RN
[email protected]
TA37: Tobacco Treatment for Two:
Connecting Pregnant Smokers with
Evidence-Based Cessation Resources
Dartmouth-Hitchcock Concord
Hilary K. Alvarez, MD
[email protected]
TA38: Workplace Violence in the
Emergency Department: Giving Staff
the Tools and Support to Report
Mayo Clinic
Erin Larson, RN
[email protected]
TA28: Reducing Non-Emergent Use of
the ER and Decreasing Total Cost
of Care using Collaboration
HealthPartners
Kelly Logue MA
[email protected]
TA29: Reducing Staff Injuries on a
Specialty Unit for Patients with Developmental Disabilities
Cincinnati Children’s Hospital Medical
Center
Davona Tucker
[email protected]
25th Annual National Forum on Quality Improvement in Health Care
Student Storyboards
Following is a list of all student
storyboards submitted before
November 13th. Please walk through
the Student section in Cypress 1 to
see these below and even more
student storyboard projects.
S1: A Trinity of Engagment Transforms
Care at UPMC Shadyside’s 6 Main
UPMC Shadyside
Irma D’Antonio
[email protected]
S2: ABC Patient Safety Hospital
General 450
Hospital General 450
Verónica Quiroga
[email protected]
S3: An Interprofessional Student
Health Care Collective
Yale School of Medicine
Phoebe Kuo
[email protected]
S4: Cardiff Medics’ Student-Patient
Chapter: 2013
Cardiff University
Hope Olivia Ward
[email protected]
S5: CLABSI: The Path to Zero
Tulane University School of Medicine
John Bates
[email protected]
S6: Consultation Services: A Gateway
to Patient Safety
Tulane University School of Medicine
Mingyang Liu
[email protected]
S7: Creating a Health Care
Improvement Curriculum
Baylor College of Medicine
Mitchell Peterson, Ann Chou, Nathan
Law, Matthew Rees
[email protected]
S8: Decreasing Wait Time for
Suboxone Patients
Harvard School of Public Health,
The Dimock Center
Jonathan Lichkus
[email protected]
S9: Developing a Revised Organ
Verification Protocol
Tulane University School of Medicine
Alexandra Dixon
[email protected]
S10: Dose Optimisation of Pregabalin
Prescribing to Improve Cost
Effectiveness in a Primary
Care Setting
Imperial College London
Kavita Aggarwal
[email protected]
S11: Eliminating PICU Consults
Transformed the Role of Medical
Response Teams at Cincincinnati
Children’s Medical Center
University of Cincinnati College of
Medicine
Ravi Grandhi
[email protected]
S13: Formation of a Combined New
Orleans IHI Open School Chapter
Tulane University School of Medicine
Ryan O’Holloran
[email protected]
S14: Georgetown University IHI Open
School Chapter
Georgetown University
Beth Shields
[email protected]
S15: Hospital Elder Life Program
Education to Prevent Delirium
at an Acute Care Hospital
London Health Sciences Centre
Barbra Watson
[email protected]
S16: How do Hospitals Work?
A Patient’s Orientation
Tulane University School of Medicine
Adrienne Krebs
[email protected]
S17: How Low is Too Low? A
Quality Improvement Project
about the Overtreatment of
Diabetes Mellitus in the Elderly
Louis Stokes VA Medical Center
Tania Jaber
[email protected]
S18: Impact of Quarterly
Interdisciplinary Medication Reviews
on Resident Care in a Canadian
Long-Term Care Facility
University of Waterloo
Linda Zhao
[email protected]
S19: Implementation and Evaluation
of a Practice Guideline for the
Management of Respiratory
Distress Syndrome in Preterm Infants:
A Quality Improvement Initiative
Athabasca University/ London Health
Sciences Centre
Brooke Read
[email protected]
S20: Implementation of a Nurse-Driven
Foley Catheter Removal Protocol
New Orleasns Healthcare
Improvement Group
Andrew Wickerham
[email protected]
S21: Implementing a Revised Organ
Verification Protocol
Tulane University School of Medicine
Tim Lindsay
[email protected]
S22: Implementing Lean to Reduce
Appointment Length
University of Michigan Medical School
Bess Connors
[email protected]
S23: Implementing the Strong for
Surgery Checklist
University of Washington
Catherine Kling
[email protected]
S24: Improvement of Hand Hygiene in
the Post-Anesthesia Care Unit
University of Illinois at Chicago
John Iskander
[email protected]
S37: QuIPS: A Student-Led
Conference Success Story
University of Toronto
Sabrina Kun Tang
[email protected]
S44: Test of a Family-Centered
Discharge Tool
Portland State University
Emily Henke
[email protected]
S25: Improving the Assessment of
Febrile Children in Primary Care:
Small Steps to a Big Change
Cardiff University
Beth Mclldowie
[email protected]
S38: Reducing Musculoskeletal
Pain-Related Nonurgent ED Visits
Cleveland VA Medical Center
Mary Angelynne Esquivel
[email protected]
S45: The Development and Growth
of the PSU & OHSU IHI Open
School Chapter
Portland State University
Cassandra Dictus
[email protected]
STORYBOARDS
S12: Empowering Students Through
Interprofessional Education,
Leadership to Promote Health Care
Improvement & Patient Safety
The University of Oklahoma Health
Sciences Center
Lin Goldston
[email protected]
S26: Improving the Care of Stroke
Survivors in Wales, UK
Cardiff University
Hope Olivia Ward
[email protected]
S39: Remote Screening for Diabetic
Retinopathy Using Non-Mydriatic
Camera
Kaiser Permanente
Manjula G Vaghjiani
[email protected]
S27: Instituto Nacional de
Enfermedades Respiratorias
Instituto Nacional de Enfermedades
Respiratorias
Nelson Rodrigo Cruz Castellanos
[email protected]
S40: Student Experience: Systems
Design for Non-Medical Student
Placements
Western University
Kelly Ainge
[email protected]
S47: Under Siege: The Bed
Management Battle
Galway Roscommon University
Hospitals
Marese Murphy
[email protected]
S28: Investigating Primary Care
Incident Reporting
Cardiff University
Amy Butlin
[email protected]
S41: Studying the Impact of Choosing
Wisely Campaign
Rutgers University
Santosh Bhaskarabhatla
[email protected]
S48: University of Cincinnati
IHI Open School Chapter
University of Cincinnati
Elizabeth Hathaway
[email protected]
S29: Longitudinal Family Medicine
Improvement Curricula
Oregon Health and Science University
and Portland State University
Bridget Lynch, MD
[email protected]
S42: Surgical Safety Checklist
Implementation
Tulane University School of Medicine
Ryan O’Holloran
[email protected]
S49: “What Can I Do to Improve
Your Stay Today?”—Interprofessional
Health Care Students Improving
Patient Care at the Bedside
Cardiff University
Hope Olivia Ward
[email protected]
S30: Morbidity and Mortality
Conference Dedicated to Quality
Improvement
Huntington Memorial Hospital
Gabriella Pearlman
[email protected]
S31: N4CAST: A Nursing Staff
Forecasting and Planning Tool
London Health Sciences Centre /
University of Toronto
Jennifer Yoon
[email protected]
S32: OHSU Newborn HepB
Immunization Improvement Campaign
Oregon Health and Science University/
Portland State University
Brandon Lynch
[email protected]
S43: Taking Time to Care for
Ourselves: A Breast Cancer
Awareness Event
Bellin College
Hannah Jochman
[email protected]
S46: The Quality Improvement
Learners Team (QILT)
Portland State University
Kelsey Priest
[email protected]
Highlighted storyboards are those that
will be presented during a Storyboard
Walkaround A, B, C, D, or E session.
S33: Patient Empowerment Impact on
Surgical Safety Checklist Compliance
Tulane University Hospital and Clinics
Elizabeth Wingo
[email protected]
S34: Preparing Students for
Residency—Simulation Bootcamp
University of South Dakota
Rebekka Sneed
[email protected]
S35: Quality Improvement at a
Student-Run Free Clinic
Tulane University School of Medicine
Mingyang Liu
[email protected]
S36: Quality’s Sustainable
Development Contest: The Triad that
Leads Health Care Improvement
Universidad del Valle de México
Uribe Pacheco Rodrigo
[email protected]
57
PRESENTER
Index
A
Adams, Laura................................ L15
Anand, Shikha............................... L11
Angel, Clay............................ A17, B17
Crocker, Liz....................................C18
Crowe, Ginna........................ L25, M11
Cummings, Ormella..................... VSV9
Curtis, Kevin..........................D13, E13
B
Baker, Neil............................ A10, B10
Balestracci, Davis............................ M7
Balik, Barbara.........L23, M1, A21, B21
Banerjee, Jay.........................D14, E14
Barrington, Monica........................C24
Barton, Kelly................................ VSV8
Batalden, Paul............................... L10
Belkin, Gary...................................C12
Bell, Donna................................... M19
Bell-Polson, Deb............................ FE3
Benjamin, Evan.......................M2, C19
Bennet, Jennifer............................RFE
Bennett, Karen............................... L21
Bennett, Brandon......................... M19
Benneyan, James........................... M5
Bernard, Peter.............................. RFB
Berry, Leonard.............. A12, B12, FE7
Berwick, Donald..........M9, C22, E1, K4
Betancourt, Joseph........................ L26
Bevan, Helen............... M10, A16, B16
Bhaskarabhatla, S.........................SWC
Bieling, Peter........................ A25, B25
Bihrle Johnson, Marian.................. FE5
Bintz, Marilu................................ VSV8
Bisognano, Maureen........................K1
Bitton, Asaf.................................... L20
Boehler, Rich.................................C10
Bones, Kate................................... FE4
Bosch, Sheila...................................C8
Boudreau, Karen........................... M15
Boulton, John.................................. L7
Bourn, Scott...........................D20, E20
Boyd, Larry.................................. VSV9
Brooks, Kristen..................... A17, B17
Brooks, Kathryn.................... A20, B20
Brownlee, Shannon..........................A1
Brummel-Smith, Ken.................... M18
Butts, Sue..................................... M11
D
Dagi, T Forcht........................D21, E21
Dalton, David................................. L30
D’Angelo, John.......................D24, E24
Davidoff, Frank.............................. L10
Davies, Louise................................ L10
Davies, Mik....................................RFA
Davis, Haidee...................... B1, D6, E6
Davis, Nancy................................. RFD
Deao, Craig................................D7, E7
DeBartolo, Kate..............L12, A13, B13
Deen, Jana................................... M22
Delbanco, Tom.................................C1
Deremo, Dorothy........................... M18
Dickson, Eric.................................. FE6
Digioia, Anthony....... A4, B4, C23, D17 .
..................................................... E17
Diller, Thomas....................... A26, B26
Dilling, James.............................. VSV7
Doerfler, Martin......................D24, E24
Dolin, Jordan................................ RFD
Dorney Koppel, Grace Anne...........C15
Downes, Tom........................ L14, M13
Duncan, Kathy.......................FE3, A13.
............................................ B13, C23
DuPree, Erin................................... M9
C
Calderon, Alvin............................... L28
Carpenter, Christopher...........D14, E14
Carter, Randall...................... A21, B21
Chafetz, Lynne................................ M4
Chase, Alide.................VSV3, D18, E18
Chassin, Mark................................. M9
Cherouny, Peter............................. L25
Chow, Marilyn................. C4, D11, E11
Christensen, Mylia......................D4, E4
Classen, David.......................... A3, B3
Clemmer, Terry.............................. M24
Cochran, John............................. VSV3
Cohen, Gary..................................... E1
Cohen, Sandy (Alexander).............. L16
Coleman, Eric............................... M17
Colletti, Richard............................. L17
Compton-Phillips, Amy...........D12, E12
Connors, B....................................SWD
Constantine, Roy....................D21, E21
Conway, William........................... VSV5
Cooper, Andrew............................. L18
Coye, Molly................................... RFB
Crandall, Wallace........................... L17
Crane, Joseph................L13, A18, B18
Crisp, Nigel............................. B1, C12
58
E
Eby, Doug............................... L3, M20
Ely, E Wesley................................. M24
F
Fahy, Patricia...................................C7
Fairman, Steve...................... A16, B16
Federico, Frank....... L29, A24, B24, C5 .
.............................................D22, E22
Feeley, Derek.........................D25, E25
Ferrans, Richard........................... RFD
Ferrigno, Rock...........................D8, E8
Fisher, Michael............................ VSV6
Fitzgerald, Elaine............................ L11
France, LeLayna..............................C8
Frankel, Allan................................ M21
Fraser, Sarah................................ M14
Fredriks, Dean.......................D11, E11
G
Galli, Brian J................................. RFD
Gandhi, Tejal.................................. L27
Gelmon, Sherril..........................D4, E4
Genzer, Kristie........................D16, E16
Geraghty, Barbara..................D26, E26
Gerhard, Carrie..................... A14, B14
Glisson, Rachael............................C17
Godfrey, Marjorie............................ L14
Gottlieb, Katherine........................ M20
Gould, Bernice.......................D15, E15
Grandhi, Ravi................SWA, D19, E19
Grange, Christina...........................C17
Gray, Rosamund...................M19, RFE
Greene, Hugh........................... A8, B8
Griffin, Fran................................... FE2
Grogan, Mary Ellen………….D26, E26
Gruner, Dean.............................D5, E5
Guenther, Robin............................... E1
Gunther-Murphy, Christina.....FE6, A13.
............................................ B13, C20
Gustafson, David................... A19, B19
Guy, Matthew.................................RFE
H
Haas, Derek...............................D3, E3
Haerkens, Marck...........................C25
Hamnett, Paul............................... RFD
Hanley, Bill......................................C2
Hannenberg, Alexander.........D21, E21
Hanson, Daniel.............................. L28
Haraden, Carol........................ L27, M8
Hart, Robert...........................D16, E16
Haskell, Helen.......................D18, E18
Hatoun, Jonathan..................D19, E19
Hayward, Martha...........L23, A21, B21
.............................................D18, E18
Healy, Maureen......................D26, E26
Henriks, Goran.......L5, VSV1, M14, B1, .
.............................................D12, E12
Hiltonen, Beth..................................C8
Homer, Charles.............................. L11
Horowitz, Leora............................. .L19
Hunt, Jacquelyn............................. L15
J
Jack, Brian.................................... L19
Jacobsen, Diane....................D24, E24
James, Brent........................... M5, M9
Jarman, Brian................................C22
Jarrett, Mark.................................... L8
Jensen, Kirk...................L13, A18, B18
Jervis, Ramiro................................C14
Johnson, Cheri............................... L25
Jordan, Victoria............................... M5
K
Kabcenell, Andrea................... L22, M1
Kanter, Michael......................D27, E27
Kantrowitz, Michael................D19, E19
Kaplan, Gary................................. M16
Kenney, Linda............................... M22
Kershaw, Sean.................................C2
Kerwin, George............ L18, VSV2, C13
Kinkead, Laura................................ M6
Kirby, Thornton..................... A26, B26
Knox, Peter.......................... L18, VSV2
Knudson, Susan.............................C16
Kotagal, Uma......................... L2, VSV6
Kramer, Stacy................................RFE
Krause, Jean......................... A14, B14
Krause, Christina............................. M3
Krueger, John..................................C9
L
Labinjoh, Catherine............... A22, B22
Lachman, Peter...................... L9, M23
Laderman, Mara........................... M15
Laing, Shirley................................ M19
Leavitt Gullo, Sue................... L25, FE1
Leitch, Jason.... L9, M19, B1, D25, E25
Leiterman, Gretchen..................D2, E2
Lenarz, Loie (Lois)........................... M6
Leonard, Michael.......................... M21
Levy, Paul......................FE4, D19, E19
Lewis, Ninon.................L12, M19, RFE
Lichkus, J.....................................SWB
Litvak, Eugene................................. L9
Liu, Michael...............................D3, E3
Lloyd, Robert...........L5, FE2, A15, B15
Loehrer, Saranya............................ FE1
25th Annual National Forum on Quality Improvement in Health Care
Longmate, Andrew............... A22, B22,
.............................................D12, E12
Lown, Beth....................................C18
Luther, Katharine.............L2, A15, B15
.................................................D3, E3
Lynn, Joanne................................ M18
M
MacKenzie, Simon........................... L7
Madigosky, Wendy.................... A9, B9
Madsen, Victoria................... A25, B25
Magnan, Sanne................................C2
Maher, Lynne................................... L6
Mahoney, Mary................................ L8
Makoul, Gregory.....................D13, E13
Mann, Sharon..................................C6
Margolis, Peter..................... L17, VSV6
Mate, Kedar........................M8, D6, E6
Mayer, David..........................D19, E19
McCannon, Jessica........................ L24
McCannon, Joe.......................M8, RFA
McCarthy, Chris............................... L6
McCracken, Kris............................ L26
McCutcheon Adams, Kelly.... L24, M24 .
.................................... C20, D10, E10
McIlwain, Thomas......................... M13
Meaker, Rob............................. A2, B2
Memoracion, Elena................... A7, B7
Merrithew, Nicole.......................D4, E4
Micalizzi, Dale Ann........................ M23
Moen, Ronald................................C11
Mondoa, Catherine................ A22, B22
Moon, Tania................................... L17
Moriarty, Katie............................D2, E2
Morrison, Kristin.....................D19, E19
Moses, James................... FE5, A9, B9
Munch, David............................... M12
Murray, Sandra................L4, A11, B11
.............................................D10, E10
N
Nicolaou, Lisa................................ L21
Nielsen, Gail......................... L19, M17
Niemann, Jason.................... A24, B24
Nohr Beck, Lindsay..........................K3
Nolan, Kevin......................... A18, B18
Norouzzadeh, Shaghayegh............... L1
O
Ogrinc, Greg.................................. L10
O’Leary, Dennis................................C4
Orlikoff, Jamie................................. M2
O’Shaughnessy, Patrick................... M9
Ovretveit, John.................................C3
P
Pabo, Erika.................................... L20
Parmentier, Darlene...............D24, E24
Parry, Gareth.................................. L16
Parsons, Tamera............. VSV9, A6, B6
Peden, Carol.................................. L29
Penner, Josef........................ A11, B11
Perla, Rocco.................................... L4
Peterson, Kathleen.........................C26
Phillips, Jennifer.......................M4, C6
Pinto, Carlos..................................C26
Plsek, Paul...................................... M4
Poku, Asantewaa...........................C14
Posencheg, Michael.......................C11
Power, Maxine...............L30, D23, E23
Priest, K........................................ SWE
R
Raj, Prince.................................D8, E8
Ramsay, Rebecca..........L22, A20, B20
Ray, Deborah.................................C11
Reid, Amy...................................... L16
Reiss-Brennan, Brenda................. M15
Richmond, Mike................. B1, D6, E6
Roberts, Christopher................. A2, B2
Robson, Brian................................ L15
Romagnoli, James............................ L8
Ruelas, Enrique.........................D6, E6
Rukat, Agata................................ VSV1
Rutherford, Patricia............... L19, M17
Ryckman, Frederick..................... VSV6
S
Sadler, Blair............................ M22, E1
Saeed, Shahab.................................D1
Saini, Vikas......................................A1
Sands, Kenneth.............................C19
Santrach, Paula........................... VSV7
Sayers, Diane................................. L21
Scanlon, Kerri Anne.................. A7, B7
Scanlon, Matt................................ M23
Schall, Marie.......... M8, RFA, D10, E10
Schaub, Diane.......................... A5, B5
Schellekens, Wim.................... B1, C25
Schilling, Lisa.............. L2, RFA, D3, E3
Schraeder, Lisa......................D17, E17
Schreiber, Michelle...................... VSV5
Scott, Michael....................... A24, B24
Scott, Carolyn............................ A6, B6
Scoville, Richard..................L1, D9, E9
Seguin, Cara.................................. L21
Selberg, Jeffrey..............................C22
Sevin, Cory..................................... L20
Shabot, M. Michael...................... VSV4
Shewale, Jitesh......................... A5, B5
Silversin, Jack............................... M16
Skootsky, Samuel.......................... RFB
Smith, Coleen....................... A26, B26
Smith, Kristofer..............................C14
Smith, Andrea........................D27, E27
Smith, Kevin................................... M3
Snyderman, Nancy..........................K3
Sodzi-Tettey, Felix K. Sodzi...............B1
Solazzo, Mark.................................. L8
Spear, Steven................................ M13
Spuhler, Vicki................................ M24
Staines, Anthony............................ L29
Stearns, Myra.................................C15
Steinfield, Rebecca........................ L20
Stevens, David............................... L10
Stewart, Kevin............................... M22
Stiefel, Matthew.............................C16
Sugarman, Jonathan...................... L20
Swanson, Julia............................. VSV5
Swensen, Stephen......................... FE7
T
Taigman, Mike.......................D20, E20
Taitz, Jonny................................... M23
Tan-Mcgrory, Aswita....................... L26
Taylor, Jane................................... M11
Terris, Darcey.................................C17
Thompson, Jeff................................ E1
Thompson, Ken............................ M14
Tierney, Steve................................... L3
Toussaint, John......... A12, B12, D5, E5
Troyer, Drew.....................................C9
Tufano, Amy................................... M4
V
Van Der Hoeven, Johannes G.........C25
Van Straten, Randy........................C13
Varnam, Robert............................. M10
Vyas, Dimple..................................C21
W
Wagner, Robin...............................C27
Walker, Jan......................................C1
Warren, Abigail......................D23, E23
Warshaw, Harriet............................ L24
Webster, Patty................................ L12
Weihenmayer, Erik...........................K2
Weingarten, Scott...................... A3, B3
Weiss, Kevin..................................C27
Wen, Leana........................... A23, B23
White, Maureen........................ A7, B7
White, Lynn............................D20, E20
White, Kristine................................ L23
Whittington, John................... L22, C21
Williams, David............ M12, A15, B15
.............................................D20, E20
Willson, Alan.................................. L18
Woebbeking, Laura....................... RFD
Wolfson, Daniel................................A1
Wolterman, Dan........................... VSV4
Wong, Winston.......................D15, E15
Worden-Kirouac, Elisa......................C8
Wozney, Bradley........................... RFB
Wright, Jean...................................C15
Y
Yates, Gary................................M9, C5
Yokoe, Deborah..............................C23
PRESENTER INDEX
Provost, Lloyd..................L4, A11, B11
Pugh, Michael................................. M1
Puri, Ajay........................................ M3
Z
Zak, Helen....................................... L1
59
Exhibitors
Acesis
Booth #1424
2047 Old Middlefield Way
Mountain View, CA 94043
650-954-6410
[email protected]
www.acesis.com
Acesis is a cloud based platform that
manages patient safety oversight
and organizational compliance. The
system is optimized to ease date
capture, enable consistent workflow,
and support robust analytics.
Gold Sponsor
Solutions
Booth #113
Agency for Healthcare
Research & Quality
Booth #1438
540 Gaither Rd
Rockville, MD 20850
301-427-1364
[email protected]
www.ahrq.gov
Within the Department of Health and
Human Services, AHRQ is charged
with improving the quality, safety,
efficiency, and effectiveness of health
care for all Americans. AHRQ
supports research to improve the
quality of health care and promote
evidence based-decisions.
Aging with Dignity
Booth #212
ACP - American College of
Physicians
Booth #1212
190 N. Independence Mall West
Philadelphia, PA 19106
800-523-1546
[email protected]
www.acponline.org
The American College of Physicians
(ACP) is the world’s largest medical
specialty society with the attention
of more than 100,000 internists.
Resources for recruiters include:
Annals of Internal Medicine, ACP
Hospitalist, ACP Internist, and ACP
Online (the website for internal
medicine, www.acponline.org).
Advanced Practice
Strategies
Booth #713
New Exhibitor
470 Atlantic Ave, 14th Floor
Boston, MA 02210
617-275-7300
[email protected]
www.aps-web.com
Advanced Practice Strategies
accelerates high reliability in
health care delivery by measuring
and improving clinical knowledge
and judgment.
PO BOX 1661
Tallahassee, FL 32302
888-594-7437
[email protected]
www.agingwithdignity.org
National nonprofit organization:
Created the Five Wishes advance
directives used by 35,000 organizations including hospices. Available
in 27 languages and Braille. New
online resources, adolescent/young
adult, and pediatric versions.
American Academy on
Communication in Healthcare
Booth #1016
201 E. Main St., Suite 1405
Lexington KY 40507 859-514-9199
[email protected]
www.AACHonline.org
The American Academy on
Communication in Healthcare
(AACH), a non-profit organization,
provides support for education
and research to improve communication outcomes among clinicians
and across health care teams and
systems.
American Heart Association
Booth #102
7272 Greenville Ave
Dallas, TX 75231
800-242-8721
www.heart.org
The American Heart Association
and American Stroke Association
offer a complete portfolio of quality
improvement programs dedicated
to bettering patient outcomes through
guideline adherence. The programs
include offerings in heart failure,
stroke, and more.
8301 Excelsior Drive
Madison, WI 53717
888-830-2644
[email protected]
www.amphionmedical.com
Amphion is a premier provider of
technology-driven transcription,
coding, and core measures services.
Whether you need a technology
platform or outsourcing services,
Amphion can help.
Avatar Solutions
Booth #112
New Exhibitor
1000 Primera Blvd Ste. 3144
Lake Mary, FL 32746 USA
800-AVATAR4 (282-8274)
[email protected]
www.avatarsolutions.com
Avatar Solutions is an innovative
survey, data measurement, and
performance improvement company
with over 30 years of experience.
We specialize in Patient, CAHPS,
Employee, and Physician Surveys.
Baldrige Performance
Excellence Program
Booth #415
100 Bureau Drive Stop 1020
Gaithersburg, MD 20899-1020
301-975-2036
[email protected]
www.nist.gov/baldrige
The Baldrige Program promotes
organizational excellence through
assessment, feedback, and best
practice sharing. The program
develops/disseminates the Criteria
for Performance Excellence and
manages the Malcolm Baldrige
National Quality Award.
BMJ
Booth #1106
1685 South Colorado Blvd, Suite
S-271
Denver, CO 80222-4040
855-458-0579
[email protected]
company.bmj.com
BMJ provides access to the best
knowledge and improvement tools
essential for delivering quality
healthcare. These are applied in
cases ranging from treating a patient
to allocating finite resource.
Amphion Medical
60
25th Annual National Forum on Quality Improvement in Health Care
Board of Pharmacy
Specialties
Booth #915
New Exhibitor
2215 Constitution Avenue NW
Washington, DC 20037
202-429-7542
[email protected]
www.bpsweb.org
The Board of Pharmacy Specialties
(BPS) is an autonomous Division of
the American Pharmacists Association
(APhA), founded in January
1976 to recognize specialties and
certify pharmacists in specialized
areas of pharmacy practice. Six
specialties are currently recognized
by BPS, including: 1) nuclear
pharmacy, since 1978; 2) nutrition
support pharmacy, since 1988; 3)
pharmacotherapy, since 1988; 4)
psychiatric pharmacy, since 1992;
and 5) oncology pharmacy, since
1996. 6) ambulatory care pharmacy, since 2011. More than 15,800
pharmacist specialists are currently
certified by BPS.
Care COPILOT™
by Allina Health
Booth #516
New Exhibitor
2925 Chicago Avenue
Minneapolis, MN 55407
612-262-5056
[email protected]
www.healthcarecopilot.com
Care COPILOT reflects research
from Allina Health and the University
of Minnesota. Aimed at optimal
management of chronic illnesses,
Care COPILOT disseminates the
Care Guide Model to health care
organizations nationwide.
Care Team Connect
Booth #1418
518 Davis St Ste 230
Evanston, IL 60201
877-736-4631
[email protected]
www.careteamconnect.com
Care Team Connect’s integrated care
management platform powers innovative population health strategies. Our
secure, web-based platform enables
creation of shared patient-centric
care plans to power cross continuum
coordination and collaboration.
CECity.com, Inc.
Cerner Corporation
Columbia HeartSource
Booth #407
Booth #1101
Booth #817
285 Waterfront Drive East, Suite 100
Homestead, PA 15120
412-338-0366
[email protected]
www.cecity.com
CECity.com, Inc. is the leading
provider of cloud-based quality
reporting, performance improvement,
and lifelong learning platforms.
Center to Advance
Palliative Care
Booth #209
1255 Fifth Avenue, Suite C2
New York, NY 10029
212-201-2670
[email protected]
www.capc.org
The Center to Advance Palliative
Care (CAPC) provides health care
professionals with the tools, training,
and technical assistance necessary to
start and sustain successful palliative
care programs in hospitals and other
health care settings.
Platinum Sponsor
Booth #1112
New Exhibitor
100 Centurion Way
Williamston, MI 48895
800-248-4058
[email protected]
www.centurionmp.com
Centurion develops unique products
with critical input from clinicians.
Featuring the CVC Zone Bundle – a
central line insertion bundle with
everything you need to help prevent
CLABSIs and improve outcomes.
Monday, December 9
3:30 PM – 6:30 PM
2800 Rockcreek Pkwy
Kansas City, MO 64117
816-221-1024
[email protected]
www.cerner.com
21 Audubon Avenue, 2nd Floor,
Room 209
New York, NY 10032
212-305-9317
[email protected]
www.columbiaheartsource.org
Cerner is contributing to the systemic
change of health and care delivery.
For more than 30 years, Cerner has
been executing its vision to make
health care safer and more efficient.
Cerner is building on the knowledge
that is in the system to support
evidence-based clinical decisions,
prevent medical errors, and empower
patients in their care.
Columbia HeartSource is a
management services group at
Columbia University Medical Center.
We customize solutions to enhance
cardiovascular programs and help
our affiliates to succeed and grow
in an ever-evolving health care
environment.
Chameleon Corporation
Booth #106
10:30 AM – 1:30 PM
Booth #100
633 N Saint Claire St.
Chicago, IL 60611
312-202-5085
[email protected]
www.facs.org/cancer
1:00 PM: Forum Fortune Drawing
625 Bakers Bridge Suite 105
Franklin, TN 37067
615-656-3280
[email protected]
www.chameleonwhiteboard.com
Chameleon, the world’s first
interchangeable whiteboard,
provides an entirely erasable
surface (no staining, shadowing
or ghosting) while providing for
cost effective content/language
changes through the use of
interchangeable inserts.
CHG Hospital Beds
Booth #1201
1020 Adelaide St South
London, ON N6E1R6
519-963-4010
[email protected]
www.chgbeds.com
CHG is the leader in low beds. To
optimize patient safety, “Select”
features a 10” low height, scale,
multi-zone bed exit alarm, open
architecture, antibacterial
rails/boards, and more.
CipherHealth
Commission on Cancer
For more than a century, the American College of Surgeons has focused
on quality patient care. Through the
Commission on Cancer Accreditation
Program, providers demonstrate their
commitment to providing high-quality
patient care.
Commonwealth Fund
Booth #413
1 East 75th Street
New York, NY 10021
212-606-3800
[email protected]
www.commonwealthfund.org
The mission of The Commonwealth
Fund is to promote a high performing health care system that achieves
better access, improved quality, and
greater efficiency, particularly for
society’s most vulnerable.
Gold Sponsor
Booth #814
New Exhibitor
555 8th Avenue
New York, NY 10018
617-820-4241
[email protected]
www.cipherhealth.com
CipherHealth provides care
continuity solutions that improve
hospital efficiency and patient
satisfaction. Our post-discharge
communication platform helps
hospitals reduce preventable
readmissions and increase
HCAHPS while ensuring
resources are utilized effectively.
Conifer Health Solutions
Booth #1200
2401 Internet Blvd. Suite 201
Frisco, TX 75034
877-CONIFER
[email protected]
www.coniferhealth.com
Everything we do at Conifer Health
Solutions is rooted in our commitment to transforming health care by
enhancing the patient experience,
supporting financial improvement,
and driving value-based performance.
Welcome Reception
4:30 PM – 6:30 PM
Tuesday, December 10
9:30 AM – 10:30 AM
(By appointment only)
10:30 AM – 1:30 PM
4:15 PM – 6:30 PM
Storyboard Reception
4:30 PM – 6:30 PM
Wednesday, December 11
Cooper Signage &
Graphics
Booth # 217
New Product Release
2405 Lance Court
Loganville , GA 30052
770-736-1522
[email protected]
www.wayfindingforhealthcare.com
CS&G is recognized as the
preeminent leader in designing
and providing wayfinding systems
for health care facilities. CS&G’s
wayfinding services and products
have been awarded the exclusive
endorsement of the AHA.
EXHIBITORS
Centurion Medical Products
New Exhibitor
New Exhibitor
Exhibit Hall
Hours
Courtemanche &
Associates
Booth #908
4475 Morris Park Drive, Suite B
Charlotte, NC 28227
704-573-4535
[email protected]
www.courtemanche-assocs.com
Courtemanche & Associates is a
nationally recognized health care
consulting firm specializing in
regulatory and accreditation,
leadership development, quality
and safety improvement, and
ongoing support for health care
leaders, administrators, and
practitioners.
Which exhibit booths did you visit? Tweet it using #IHI25Forum
61
Exhibitors
Creative Healthcare
Gold Sponsor
Gold Sponsor
CHC provides tools and training
to support efforts in health care
improvement. We train and
certify in Lean, Six Sigma and also
ISO - deployment. Online and onsite
training options available.
Crimson, A Division of The
Advisory Board Company
Booth #601
2445 M St NW
Washington, DC 20037
202-266-6639
[email protected]
www.advisory.com/crimson
A national technology-based
collaborative designed to support
providers in the migration towards
value-based care. Currently
supporting 1200+ hospitals,
20+ clinically integrated networks
and 400K+ physician cost and
quality profiles.
Dartmouth College—Master
of Health Care Delivery
Science Program
Booth #522
37 Dewey Field Rd Ste. 200 HB 7253
Hanover, NH 03755
603-646-1222
[email protected]
www.mhcds.dartmouth.edu
Designed for accomplished working
professionals, Dartmouth’s 18-month
Master of Health Care Delivery
Science program equips students
with new skills and knowledge to
lead the vital transformations taking
place in health care today.
Datix (USA) Inc
Booth #206
155 North Wacker Drive Suite 4250
Chicago, IL 60606
312-803-4991
[email protected]
www.datixusa.com
Patient safety and risk management
software to spot trends as events
occur, reduce future harm by prioritizing risks and creating corrective
actions. Integrated reporting and
configurable dashboards capture
real time information. Over 20 years
proven experience in health care
settings worldwide.
62
DNV Healthcare Inc.
Booth #513
DebMed LLC
Booth #1107
2815 Coliseum Centre Drive,
Suite 600
Charlotte, NC 28217
704-357-4258
[email protected]
www.debmed.com
The DebMed® Group Monitoring
System (GMS™) is the world’s first
electronic hand hygiene monitoring
system developed from proven
scientific research. It tracks not
just how many times staff cleaned
their hands, but how many times
they should have cleaned their
hands, based on the World Health
Organization’s Five Moments for
Hand Hygiene.
400 Techne Center Dr. Suite 100
Milford, OH 45150
281-685-9996
[email protected]
www.dnvaccreditation.com
DNV Healthcare is the leading
accreditor of US hospitals integrating
ISO 9001 quality compliance with the
Medicare Conditions of Participation.
Our NIAHO® accreditation platform
helps you achieve constant readiness.
Dwelling at Ease
Booth #1309
Located in the
Wellness Pavilion
New Exhibitor
Dialog Medical
Booth #706
30 Perimeter Park Drive Suite 200
Atlanta, GA 30341
800-482-7963
[email protected]
www.dialogmedical.com
Dialog Medical’s iMedConsent™
application produces easy-to-understand, procedure-specific consent
forms, discharge instructions, and
patient education materials. Trusted
by over 200 hospitals, iMedConsent™
enhances safety, manages risk,
ensures compliance, and lowers costs.
Dimensional Insight
Booth #801
60 Mall Road
Burlington, MA 01803
781-229-9111
[email protected]
www.dimins.com
Hundreds of hospitals use The
Diver Solution to tackle productivity,
quality, revenue cycle, and clinical
challenges. Clinical, financial, and
operational data from multiple sources
can be easily integrated with Diver.
Booth #1007
1 Edwards Way
Irvine, CA 92614
949-250-2500
[email protected]
www.edwards.com
Booth #612
101 North Acacia Avenue,
Suite 101
Solana Beach CA 92075
858.473.2525
[email protected]
www.creative-healthcare.com
Edwards Lifesciences
Jamestown, RI 02835
401-487-4434
[email protected]
www.dwellingatease.com
Dwelling at Ease® promotes fall
prevention and home safety through
real-time web-based systems that
analyze and address hazards and
obstacles to accessibility, reducing the
risk of falls and accidental injuries.
ECRI Institute
Booth #308
5200 Butler Pike
Plymouth Meeting, PA 19462
610-825-6000
[email protected]
www.ecri.org
ECRI Institute is an independent
nonprofit that researches the best
approaches to improving patient
care. Our unbiased, evidence-based
research, information, membership
program, and educational services
help you to lead your organization in
assessing and addressing safety, quality, and risk management challenges.
25th Annual National Forum on Quality Improvement in Health Care
Edwards Healthcare Provider
Solutions is your expert advisor
in clinical process improvement.
Programs include the Sepsis
Management Program and
Post-Surgical Recovery Program
focused on reducing critical
complications in your hospital.
Eloquest Healthcare, Inc.
Booth #923
New Exhibitor
780 West Eight Mile Rd
Ferndale, MI 48220
877-433-7626
[email protected]
www.eloquesthealthcare.com
We care about the care you deliver.
At Eloquest Healthcare®, we focus
on delivering easy-to-use product
solutions that minimize infection risk,
lower treatment costs, and increase
patient and caregiver satisfaction.
Elsevier
Booth #313
245 Peachtree Center Ave NE
Atlanta, GA 30303
866-430-7062
[email protected]
www.clinicaldecisionsupport.com
Elsevier is a global leader in providing
health information and performance
improvement solutions. Our worldclass information and point-of-care
technologies optimize decisions and
actions to improve the overall quality,
safety, and cost-effectiveness of care.
Endur ID
Booth #215
8 Merrill Industrial Dr
Hampton, NH, 03842
603-758-1488
[email protected]
www.endurid.com
Endur ID will be presenting our
Patient Identification Solutions.
Endur ID’s solution includes
wristband media and software.
Endur ID wristbands are in
color, waterproof, easy to
produce, and comfortable.
Health Catalyst
HealthStream, Inc.
i2i Systems
Booth #105
Booth #715
Booth #1006
Booth #1000
209 10th Avenue South, Suite 450
Nashville, TN 37203
615-301-3100
[email protected]
www.healthstream.com
3663 N. Laughlin Road, Suite 200
Santa Rosa
707-575-7100
[email protected]
www.i2isys.com
Over half of US hospitals use
HealthStream’s research, learning,
simulation, and talent management
solutions to improve outcomes. Learn
how we support better healthcare
quality and experiences on our
website.
A leading provider of population
health and business intelligence
solutions, i2i Systems helps health
care organizations deliver better
care more efficiently at a lower
cost through software, services,
and community.
HealthTeamWorks
Institute for Healthcare
Improvement (IHI)
New Exhibitor
New Exhibitor
44 Montgomery St. Suite 3500
San Francisco, CA 94104
866-692-4271
[email protected]
www.engineeredcare.com
3165 Millrock Drive, Suite 400
Salt Lake City, UT 84121
801-708-6800
[email protected]
www.healthcatalyst.com
From the hospital to the home,
Engineered Care improves the patient
experience with evidence-based,
interactive solutions that manage the
patient relationship.
Health Catalyst provides a transformational approach to health care
analytics and data warehousing. Learn
more about our rapidly deployed data
warehouse and quality improvement
solutions by visiting our website.
GE Healthcare
Booth #223
N16W22419 Watertown Road
Waukesha, WI 53186
877-438-4788
[email protected]
www.gehealthcare.com/education
GE Healthcare’s Fetal Heart Rate
Monitoring Program and Nursing
Library of Online Education with
more than 50 courses helps clinicians
stay current with best practices and
optimize patient care.
Georgia-Pacific Professional
Booth #1205
New Exhibitor
133 Peachtree St.
Atlanta, GA 30303
404-652-6132
[email protected]
www.gp.com
Georgia-Pacific Professional is a provider of hygienic dispensing systems,
towels, tissues, soaps, cups and more
including a full range of products to
service the healthcare segment. It
features well-known product brands
enMotion® Compact® and Dixie®.
Health Care DataWorks
Booth #108
New Exhibitor
1801 Watermark Drive
Columbus, OH 43215
614-255-5400 or 877-979-4239
[email protected]
www.hcdataworks.com
HCD empowers health care
organizations to improve their
quality of care and reduce costs.
Our KnowledgeEdge™ solution delivers an Enterprise Data Warehouse
that enables hospitals and health
systems to gain operational visibility
and insight.
Health Dialog
Booth #216
New Exhibitor
Booth #1308
Located in the
Wellness Pavilion
274 Union Blvd. Suite 310
Lakewood, CO 80228
303.446.7200
[email protected]
www.healthteamworks.org
New Exhibitor
60 State Street Suite 1000
Boston, MA 02109
617-406-5200
[email protected]
www.healthdialog.com
Health Dialog is a leading provider
of health care analytics and decision
support. Company offerings include
health coaching for medical
decisions, chronic conditions,
and wellness; population analytic
solutions; and consulting services.
Health Information
Alliance, Inc. (HIA)
HealthTeamWorks is a nonprofit,
multi-stakeholder collaborative
working to redesign the healthcare
delivery system and promote
integrated communities of care
using evidence-based medicine,
practice transformation coaching,
and innovative systems.
Horizon Health
Booth #214
New Exhibitor
2941 Lake Vista Drive, Ste 100
Lewisville, TX 75067
800-727-2407
[email protected]
www.horizonhealth.com
Booth #224
New Exhibitor
Founded in 1981, Horizon Health
Behavioral Health Services is the
leading manager and provider of
hospital-based behavioral health
programs, working with hospitals
of all types and sizes.
438 Marion Ave.
Ambler, PA 19002
800-405-8800
[email protected]
www.HIA-CORP.com
HIA is focused on assisting its clients
with the highest quality outcomes. HIA’s clients won the TJC’s Top
Performers on Key Quality Measures
this year as well as Thomson Reuters
Top Hospitals.
Healthier Hospitals Initiative
Booth #912
12355 Sunrise Valley Drive
Reston, VA 20191
703-405-8758
[email protected]
www.healthierhospitals.org
Healthier Hospitals Initiative (HHI) is
a free, three-year initiative designed to
accelerate the use of environmental
interventions throughout the health
care sector for improved health of
patients, staff, and community.
HQI Partners
Booth #907
2966 South Church St
Suite #247
Burlington, NC 27215
(336) 395-1420
[email protected]
www.HQIpartners.com
HQI Partners is a national provider
of core measure abstraction and
quality improvement consulting
services. Our vision is to support
our clients in the delivery of
perfect care.
EXHIBITORS
Engineered Care, Inc.
Booth #301
ISO Consultants for
Healthcare
Booth #1208
New Exhibitor
PO Box 498
Greenville, Ohio, 45331
937-569-0173
[email protected]
www.isoforhealthcare.com
Nation’s leader in integrating
health care and ISO 9001 quality
management system. ICH provides
system-oriented solutions through
effective implementation, resulting
in cost reduction and sustainable
performance improvement-focused
on patient outcomes.
Gold Sponsor
John Kim and Associates
(JKA): Lean Healthcare
Booth #417
3917 Kathleen Way
Davenport, IA 52807
563-650-3822
[email protected]
www.Johnkimconsulting.com
An industry leading Lean health
care consulting company specializing in the design, development,
and implementation of Lean
management systems customized
to the specific needs of health
systems, hospitals, physician practices and health plans.
Which exhibit booths did you visit? Tweet it using #IHI25Forum
63
Exhibitors
Joint Commission
Resources
Booth #1400
1515 W. 22nd St. Suite 1300W
Oak Brook, IL 60523
630-268-7400
[email protected]
www.jcrinc.com
Joint Commission Resources (JCR)
offers a full spectrum of resources
to help health care professionals
provide safe and efficient patient
care through consulting services,
education programs, publications
and multimedia products.
Platininum Sponsor
Joint Commission Center
for Transforming Health
Booth #103
One Renaissance Blvd.
Oakbrook Terrace, IL 60181
630-792-5630
[email protected]
www.centerfortransforminghealthcare.org
The Joint Commission Center for
Transforming Healthcare offers the
Targeted Solutions Tools, an innovative
application that customizes solutions
for your organization. Learn more
about how it can help you reduce
HAIs and more!
Krames StayWell
Booth #815
New Exhibitor
780 Township Line Road
Yardley, PA 19067
267-685-2500
[email protected]
www.kramesstaywell.com
Krames StayWell is the nation’s
largest provider of consumer health
information, patient education, and
population health management
communications. Integrating print,
digital, mobile, and social formats,
Krames StayWell is proud to offer
solutions, including a new health
communication and patient engagement program exclusively for ACOs,
to meet the needs of the changing
health care environment.
Lightshed Health
Booth #914
New Exhibitor
Lightshed gives you tools to manage
your patients’ experience of waiting
for care. They can skip the waiting
room with UrgentQ.
Booth #716
New Exhibitor
Kaiser Permanente
Booth #600
1 Kaiser Plaza
Oakland, CA 94612
510-271-5953
Please use corporate hotline.
www.kp.org
Kaiser Permanente is committed to
helping shape the future of health
care and to providing high-quality,
affordable health care services to
our 9.1 million members and the
communities we serve.
64
Medical Interactive
Booth #1012
One Galleria Blvd., Suite 700
Metairie, LA 70001
855-464-7475
[email protected]
www.medicalinteractive.com
901 Fifth Avenue, Suite 2000
Seattle, WA 98164
888-464-4746
[email protected]
www.careguidelines.com
MCG helps providers and payors
drive effective care. We provide
fast access to global, validated best
practices so you can leverage your
clinical expertise and make decisions
with confidence.
MCN Healthcare
Booth #316
1777 S Harrison St Ste 405
Denver CO 80210
800-538-6264
pam.gustafson@mcnhealthcare.
com
www.mcnhealthcare.com
MCN Healthcare is a leading provider
of health care regulatory compliance
solutions including Policy Manager,
Policy Library, and StayAlert! – e-mail
notification of regulatory changes and
implementation tools. Visit our website
to learn more.
MedAssets
Booth #1442
3423 Piedmont Rd. NE
Atlanta, GA 30345
800-729-1363
[email protected]
www.lightshedhealth.com
Loyola University Chicago
Niehoff School of Nursing
Diamond Sponsor
MCG — Formerly Milliman
Care Guidelines
2160 S. First Avenue, Bldg. 125
Maywood, IL 60153
708-216-9101
[email protected]
www.luc.edu/nursing
Loyola University Chicago announces
new Interprofessional Masters in
Quality, Safety, and Information
Technology (QSIT) for health care
clinicians and leaders. This 36 credit
program is online, with weekend
immersion each semester.
100 North Point Center East
Suite 200
Alpharetta, GA 30022
888-883-6332
[email protected]
www.medassets.com
MedAssets and Healthcare
Performance Partners, a
MedAssets Company, help health care
organizations improve theiclinical, operational, and financial performance so
they can sustainably serve the needs of
their patients and communities.
Medkinetics
Booth #1001
124 First Avenue South, Suite 200
Franklin, TN 37064
888-880-OPPE
[email protected]
www.Medkinetics.com
One system for event reporting, PSO,
pee review, FPPE/OPPE, privilege’s
with CPT/ICD-10 codes, credentialing,
and payor enrollment. You don’t need
another database, you need an interactive partner with proven results!
25th Annual National Forum on Quality Improvement in Health Care
Booth #204
Medical Interactive offers resources
designed to reduce RM expenses
and increase productivity in med
mal insurance companies and
hospitals. Our comprehensive
catalogue of products includes
CME/CE and MiCapture™
RM software.
Medical Simulation
Corporation
Booth #614
4643 S. Ulster St., #650
Denver, CO 80237
303-483-2800
[email protected]
www.medsimulation.com
Medical Simulation Corporation’s
Advanced Quality Programs enable
hospitals to measure, advance, and
sustain health care provider knowledge of evidence-based guidelines
for improved patient outcomes and
reduced health care cost.
Medworxx
Booth #812
New Exhibitor
121 Richmond St W Suite 700
Toronto, ON, M8V 1T8
800-321-1591
[email protected]
www.medworxx.com
Medworxx provides health
information technology solutions
to over 350 hospitals internationally.
Medworxx Patient Flow enables
appropriate care transitions and
fewer readmissions across the
continuum of care.
Midas+, a Xerox Company
Booth #904
4801 East Broadway Blvd.,
Suite 335
Tucson, AZ 85711
520-296-7398
[email protected]
www.midasplus.com
With approximately 1,500 clients,
Midas+ Solutions is the preferred
health care quality outcomes
improvement and strategic
performance management partner.
Minitab
Booth #607
Monarch Medical
Technologies
(formerly EndoTool)
Booth #1213
New Exhibitor
2815 Coliseum Ctr. Dr. Ste. 250
Charlotte, NC 28217
704-335-1300
[email protected]
[email protected]
www.monarchmedtech.com
Monarch Medical Technologies is the
leader in risk mitigation technologies
for drugs and processes of concern.
Its EndoTool Glucose Management
System provides unsurpassed
patient-specific control across a
broad patient population.
Morrisey Associates, Inc.
Booth #1454
222 South Riverside Plaza,
Suite 1850
Chicago, IL 60606
312-431-0123
[email protected]
www.morriseyonline.com
Established in 1987, Morrisey offers
web-based care management (case,
discharge networking, quality, risk and
infection), credentialing and privileging applications, and comprehensive
consulting services. Morrisey has over
900 health care customers.
National Board of Surgical
Technology & Surgical
Assisting (NBSTSA)
Booth #714
New Exhibitor
6 West Dry Creek Circle,
Suite 100
Littleton, CO 80120
800-707-0057
[email protected]
www.nbstsa.org
The mission of the NBSTSA is to
provide professional certification
of surgical technologists (CST) and
surgical first assistants (CSFA), thus
promoting quality patient care in the
surgical setting.
NetHealth
Booth #1422
#613
Gold Sponsor
New Exhibitor
268 Summer Street, Sixth Floor
Boston, Massachusetts 02210
617-391-9900
[email protected]
www.npsf.org
NPSF, an independent, not-for-profit
501(c)(3) organization, has been
pursuing one mission since its
founding in 1997 — to improve
the safety of care provided to patients.
National Research
Corporation
Booth #512
1245 Q Street
Lincoln, NE 68508
800-388-4264
[email protected]
www.nationalresearch.com
101 Lindenwood Drive, Suite 430
Malvern, PA 19355
610-590-2229
[email protected]
www.nethealthinc.com
Advanced technology and
collaborative consulting with custom
cloud-based PI-CME, SAM, LMS,
PQRS, patient / peer surveys and
outcomes evaluation; cutting-edge solutions that turn data into knowledge
and knowledge into improvement.
Gold Sponsor
National Research Corporation
empowers customer-centric
health care across the continuum,
transcending patient-centered
care to incorporate families,
communities, employees, and
other stakeholders, and revealing
performance improvement insights
through quality measurement.
NAVEX Global
Booth #213
New Exhibitor
6000 Meadows Road, Suite 200
Lake Oswego, OR 97035
971-250-4100
[email protected]
www.navexglobal.com
NAVEX Global’s AHA endorsed
policy & procedure management
solution helps nearly 20 percent of
the nation’s hospitals streamline
the policy management lifecycle,
eliminate paper binders, and meet
audit standards. More than 8,000
clients trust our ethics and
compliance expertise. Learn more
on our website.
NDNQI
Booth #1002
8515 Georgia Avenue, Suite 400
Silver Spring, MD 20910
301-628-5042
[email protected]
www.ndnqi.org
NDNQI®, used by 2,000 hospitals
nationwide, provides you with actionable data for quality improvement,
via comparisons against nursing
quality measurement norms of similar
hospitals down to the unit level.
North Shore-LIJ Health
System
Booth #507
145 Community Drive
Great Neck, NY 11021
516-465-8000
[email protected]
www.northshorelij.com
EXHIBITORS
1829 Pine Hall Road
State College, PA 16801
814-238-3280
[email protected]
www.minitab.com
Minitab is the leading provider of
powerful and easy-to-use quality
improvement software worldwide.
Companies rely on Minitab software,
training, and services to help them
achieve world-class quality.
National Patient Safety
Foundation
North Shore-LIJ is the nation’s
14th largest health care system,
serving more than seven million
people throughout the NYC
metro area. We partner with IHI
and others on patient safety,
performance improvement,
research and education.
Nuance Communications Inc.
NEXT LEVEL Partners, LLC
Booth #902
2338 Immokalee Road, Suite 415
Naples, FL 34110
216-632-0070
[email protected]
www.nl-p.com
NEXT LEVEL Partners, LLC is the
partner of choice if true transformation into a culture of continuous
performance improvement is desired.
Differentiators in our partnership
include competency development
structure, no minimum timeframe
of partnering work and, most
importantly, a results guarantee.
Booth #805
1 Wayside Road
Burlington, MA 01803
800-447-7749
[email protected]
www.nuance.com/for-healthcare/
index.htm
Nuance provides intelligent solutions
and services, improve the entire
clinical documentation process—from
capture of the complete patient record
to clinical documentation improvement, coding, compliance, quality
and appropriate reimbursement.
Outcome, a Quintiles
Company
Booth #1003
Nihon Kohden America, Inc.
Booth #107
90 Icon Street
Foothill Ranch, CA 92610
949-580-1555
[email protected]
nk.usa.com
Nihon Kohden will display a
complete line of enterprise
monitoring solutions, including a
robust transport system and
external device interfaces. We
will highlight clinical benefits of
implementing a Defensive
Monitoring strategy with our
Prefense™ Early Detection and
Notification System™.
201 Broadway
Cambridge, MA 02139
617-621-1600
[email protected]
www.outcome.com
Outcome is a leading provider of
web-based quality measurement
systems for quality-improvement
(QI), pay-for performance, reimbursement, accreditation, and certification
programs, providing hospitals and
physician practices with solutions
and resources to ensure quality
improvement in patient care.
Which exhibit booths did you visit? Tweet it using #IHI25Forum
65
Exhibitors
PeraHealth
PowerDMS
Booth #200
Booth #900
New Product Release
1520 South Blvd.
Charlotte, NC 28203
866-362-0001
[email protected]
www.perahealth.com
PeraHealth offers real time, clinical
decision support tools that provide
a visual representation of patient
condition. Rooted in the peer
reviewed Rothman Index™, our
tools serve the continuum of care.
Performance Logic
Booth #913
901 SE Oak St., Suite 205
Portland, OR 97214
888-407-1705
[email protected]
www.performancelogic.com
Performance Logic provides compre
hensive, web-based project portfolio
management solutions designed to
help healthcare organizations manage
projects in IT, clinical, and operational
areas while aligning resources and
goals enterprise-wide.
Physician Wellness
Services
Booth #809
5000 W 36th St #230
Minneapolis, MN 55426
800-383-1908
[email protected]
www.physicianwellnessservices.com
Physician Wellness Services provides
a coordinated, comprehensive, and
confidential suite of services designed
specifically for physicians and
organizations. We are national,
and have expertise in every
aspect of behavioral health.
Phytel
Booth #312
11511 Luna Road, Suite 600
Dallas, TX 75234
800-559-3057
[email protected]
www.phytel.com
Empowering physician-led population
health improvement, Phytel provides
proven technology to deliver coordinated patient care. Encompassing
30 million+ patients, Phytel’s registry
uses evidence-based protocols to
identify and notify patients due
for service.
66
Media Sponsor
PO Box 2468
Orlando, FL 32802
407-992-6066
[email protected]
www.powerdms.com
PowerDMS™ provides a compliance
and document management solution
that helps reduce risk and liability
with practical tools to organize and
manage crucial documents and
standards, train employees, and
prove compliance.
PQ Systems
Booth #606
210B E Spring Valley Rd
Dayton, OH 45458
800-777-3020
[email protected]
www.pqsystems.com
PQ Systems is dedicated to helping
health care professionals provide
proof of quality. Our highly regarded
CHARTrunner Lean software is the
easiest solution for improving health
care quality.
Premier Healthcare Alliance
Booth #401
13034 Ballantyne Corporate
Place
Charlotte, NC 28277
877-777-1552
[email protected]
www.premierinc.com
Premier is one of the nation’s largest
performance improvement alliances of
approximately 2,800 U.S. community
hospitals and 98,000 alternate sites
using the power of collaboration and
technology to lead the transformation
to coordinated, high-quality, costeffective care.
Press Ganey
Booth #307
401 Edgewater Drive
Wakefield, MA, 01880
978-985-7726
[email protected]
www.pressganey.com
Recognized as a leader in
performance improvement for
nearly 30 years, Press Ganey
partners with more than 10,000
healthcare organizations globally
to create and sustain high
performance and improve
the overall patient experience.
Patient Safety and Quality
Healthcare
www.psqh.com
QI Macros Lean Six Sigma
Software for Excel
Booth #101
2696 S Colorado Blvd, Suite 555
Denver, CO 80222
888-468-1537
[email protected]
www.qimacros.com
QI Macros Software for Excel
simplifies process improvement
for pareto charts and control charts.
Contains 90+ templates including
fishbones and flowcharts. Used
by 3,000+ hospitals. $229/copy.
Free 30-day trial.
Quantros, Inc.
Booth #903
475 Sycamore Drive
Milpitas, CA 95035
877-QUANTROS
[email protected]
www.quantros.com
Quantros empowers health care
providers with actionable intelligence
necessary to improve outcomes.
Our SaaS-based solutions offer safety
and risk management, quality and
performance improvement, accreditation and compliance, and centralized
decision support.
Rapid Modeling
Corporation
Booth #622
8044 Kimbee Drive
Cincinnati, OH 45244
513-624-6629
[email protected]
www.rapidmodeling.com
RMC developed Time Study
RN/MD for TCAB and manages
the Time Study RN National
Benchmarking Database. RMC
is the supplier for Lean solutions
for hospitals and health care
organizations throughout
North America.
25th Annual National Forum on Quality Improvement in Health Care
ReadyPoint Systems
Booth #1113
40 Burton Hills Blvd., Ste 150
Nashville, TN 37215
866-506-1930
[email protected]
www.readypointsystems.com
ReadyPoint’s EyeOn tool automates
rounding and survey processes.
Using a mobile device, users
complete customized surveys
and alert staff for corrective actions.
Management receives notification
of missed target dates then reminds
users to take action.
RF Surgical Systems, Inc.
Booth #517
5927 Landau Ct.
Carslsbad, CA 92008
760-827-1500
[email protected]
www.rfsurg.com
The RF Assure Detection System®
brings innovation, simplicity,
confidence, and compliance to
hospitals by providing an easy to use,
accurate system for detecting and
preventing retained surgical sponges.
RGP Healthcare
Booth # 523
New Exhibitor
90 New Montgomery Street
Suite 1301
San Francisco, CA 94105
415-369-8441
[email protected]
www.resourcesglobal.com
RGP Global formalized its offerings
into RGP Healthcare, leveraging core
competencies—project and change
management, and functional and
healthcare industry expertise—to
ensure client success on
mission-critical initiatives.
Right Brain Left Brain, LLC
Booth #222
New Exhibitor
2220 CR 210 West, Suite 108-211
Jacksonville, FL 32259
904-302-2939
[email protected]
www.rightbrain-leftbrain.net
Right Brain Left Brain is a hospital
and physician clinic services company
focused on patient centric transformation improving quality, service, and
value. We enable Joint Commission
certifications and Medicare alignment.
RightCare Solutions
Booth #1209
Skylight Healthcare
Systems
Gold Sponsor
IHI Supporter
Booth #813
New Exhibitor
RightCare Solutions provides
evidence-based software technology
that empowers nurses, discharge
planners, and case managers to
optimize care transitions and improve
patient outcomes. Our proprietary
D2S2 software, helps hospitals,
insurers and homecare agencies
improve the quality of care for patients
while reducing 30-day readmissions.
RL Solutions
Booth #701
New Exhibitor
One Broadway, 14th Floor
Cambridge, MA 02142
888-737-7444
[email protected]
www.rlsolutions.com
RL Solutions designs innovative
health care software for patient
feedback, risk management,
infection surveillance, root cause
analysis and claims management.
We have over 1300 clients, including
health care networks, hospitals,
long-term care facilities, and more.
Safer Healthcare
Booth #1456
PO Box 1010
Littleton, CO 80160-1010
866-398-8083
[email protected]
www.saferhealthcare.com
Improve and automate rounding
with MyRounding™. Take quality
improvement to the next level with
our Lean workshops. Become a
High-Reliability Organization with
our CRM solutions.
Sandlot Solutions
10935 Vista Sorrento Parkway,
Suite 350
San Diego, CA 92130
858-523-3700
[email protected]
www.skylight.com
Booth #1013
New Exhibitor
1701 River Run, Suite 902
Fort Worth, TX 76107
817-810-5210
[email protected]
www.sandlotsolutions.com
Skylight Healthcare Systems is the
industry leader in interactive patient
systems supporting the continuum of
a patient’s “journey of care” before,
during, and after the hospital stay.
Sandlot builds connections for
providers that enable the exchange
of relevant clinical content at the
point of care through “cloud”
technology. Our five-year track
record of success has facilitated
reduced cost, coordinated utilization,
improved quality, and elevated
patient satisfaction. Sandlot’s
capabilities provide the bridge to
gaps in care without exorbitant
re-engineering of current systems
and the associated expense.
SprectraMEDIX
Booth #917
New Exhibitor
66 Witherspoon Street, Suite 104
Princeton, NJ 08077
609-336-7733
[email protected]
www.SpectraMEDIX.com
SpectraMEDIX empowers hospitals
and ambulatory care providers
to improve care and maximize
revenues. Our solutions transform
real-time clinical data into
actionable information that
facilitates improved, measurable
clinical and financial results.
Gold Sponsor
Simpler Healthcare
SurgiCount Medical
Booth #306
401 Liberty Avenue
Pittsburgh, PA 15222
336-283-4060
[email protected]
www.simpler.com
Booth #1143
New Exhibitor
Using the Simpler Business System®,
Simpler sensei have delivered the
fastest and most enduring Lean
transformations at more than 85
health care networks around the world.
15440 Laguna Canyon Road
Suite 150
Irvine, California 92618
877-520-2300
[email protected] www.scmd.com
The Safety-Sponge® System utilizes
uniquely identified sponges, lap,
and towel products, providing more
accurate, real-time counts in the
operating room as well as a complete
post-operative documentation and
compliance tool.
SIMUL8 Corporation
Booth #104
225 Franklin Street
Boston, MA, 02110
800-547-6024
[email protected]
www.SIMUL8healthcare.com
The Beryl Institute
3600 Harwood Rd.
Bedford, Texas 76021
866-465-5824
[email protected]
www.theberylinstitute.org
The Beryl Institute is the
global community of practice
and premier thought leader
on improving the patient
experience in health care.
EXHIBITORS
110 Gibraltar Rd
Horsham, PA 19044
215-660-3436
[email protected]
www.rightcaresolutions.com
New Exhibitor
The Chartis Group
Booth #909
220 West Kinzie Street, 5th Floor
Chicago, Illinois 60654
877-667-4700
[email protected]
www.chartisgroup.com
The Chartis Group is an advisory
services firm that provides management consulting and applied research
to leading health care organizations.
We specialize in helping health
systems with clinical quality
improvement.
The Compliance
Team, Inc.
Booth #205
PO Box 160
Spring House, PA 19477
215-654-9110
[email protected]
www.thecomplianceteam.org
The Compliance Team’s operationsdriven Exemplary Provider™
accreditation for critical access
hospitals eliminates unnecessary
distractions and non-essential
expenses while taking a common
sense, low-cost, Gemba Kaizeninspired approach to achieving
health care delivery excellence.
For over 20 years, SIMUL8 has been
dedicated to improving health care
with simulation software. Our
customers include Geisinger, Johns
Hopkins, FUNSALUD, and the UK
National Health Service.
Which exhibit booths did you visit? Tweet it using #IHI25Forum
67
Exhibitors
Diamond Sponsor
The Joint Commission
Booth #1404
One Renaissance Boulevard
Oakbrook Terrace, IL 60181
630-792-5689
[email protected]
www.jointcommission.org
The Joint Commission accredits
and certifies more than 20,000
organizations. We provide an
educative experience that helps
organizations provide safe, high
quality care and resources to help
sustain that care.
The Quality Group, Inc
Booth #615
New Exhibitor
5825 Glenridge Dr, Suite 3-101
Atlanta, GA 30328
404-843-9525
[email protected]
www.thequalitygroup.net
The Quality Group (TQG) helps
dive Lean with health care-only
e-learning modules. Engage all
in process improvement (Lean,
six sigma, project management)
via a customized, blended
learning e-portal; deliver
ROI through better processes
and better patient care.
The STEEEP® Global
Institute
Booth #816
New Exhibitor
8080 N. Central Expressway
Suite 900, LB 77
Dallas, TX 75206
214-265-3614
[email protected]
www.baylorhealth.edu/
steeepglobalinstitute/
Pages/default.aspx
Baylor Health Care System’s
STEEEP Global Institute offers
training and consulting services
to help external organizations
improve health care quality in
the areas of safety, timeliness,
effectiveness, efficiency, equity,
and patient-centeredness.
68
Diamond Sponsor
University of Michigan
Healthcare Programs
Booth #901
The University of
Tennessee
Booth #617
Truven Health Analytics
603 Haslam Business Building
1000 Volunteer Blvd
Knoxvile, TN 37996-4160
865-974-5001
[email protected]
www.execed.utk.edu
Booth #201
UT offers CME-certified programs
and the nation’s #1 Physician
Executive MBA; delivers custom
Lean health care, Lean ED, Lean
OR and Lean for Outpatient
Settings courses; and orchestrates
on-site PI /QI events.
Truven Health Analytics delivers
leading solutions for confident health
care management. From population health and quality performance
improvement analytic platforms to
operational performance solutions,
we help hospitals, providers, and
payers improve quality, safety,
efficiency, and patient outcomes.
The Wellness Network
6200 S. Syracuse Way, Suite 300
Greenwood Village, CO 80111
303-486-6540
[email protected]
www.truvenhealth.com
Booth #916
N27 W 23539 Paul Road,
Suite 100
Pewaukee, WI 53072
888-219-4678
[email protected]
www.thewellnessnetwork.tv
The Wellness Network owns and
operates the Patient Channel and
the Newborn Channel; together the
largest and most comprehensive
in-hospital health television network
in the U.S. The Wellness Network is
also a long-time partner with the Joint
Commission Quality & Safety Network.
Thermo Scientific
Booth #1100
8365 Valley Pike
Middletown, VA 22645
800-232-3342
customerservice.diagnostics.mtn@
thermofisher.com
www.thermoscientific.com\
aboutsepsis
The Thermo Scientific’s
B•R•A•H•M•S line of immunoassays
facilitate earlier diagnosis of diseases
and better control of therapy, thus
enabling doctors to improve patient
outcomes.
UL, LLC (Underwriters
Laboratories)
Booth #1440
8131 Baymeadows Circle West
Suite 208
Jacksonville, FL 32256
904-318-7086
[email protected]
www.ul.com/lean
UL has brought together its own Lean
and six sigma transformation and
world-class leadership to accomplish
one mission: improve value to the
customer by providing higher quality
and safety with less waste. UL trains,
certifies, assesses and advises
individuals and organizations
in principles of continuous
improvement.
University of Illinois at
Chicago, College of
Medicine, Department
of Medical Education
Booth #1420
808 South Wood Street
(MC 591)
Chicago, Illinois 60612-7309
866-722-2268, Option 1
[email protected]
go.uic.edu/mpslihi
UIC’s Department of Medical
Education offers an online masters
and graduate certificate in patient
safety. These programs develop
leaders in quality patient care
practices, able to advance an
organizational culture of
patient safety.
2401 Plymouth Road
Ann Arbor, Michigan
48105-2193
734-647-7200
[email protected]
isd.engin.umich.edu
University of Michigan health care,
management, and engineering
experts offer world-class Lean
health care training with interactive
hands-on experience. Programs
can be customized for your health
care system.
University of St. Thomas
Health Care MBA
Booth #823
1000 LaSalle Ave. TMH455
Minneapolis, MN 55403
651-962-4135
[email protected]
www.StThomas.edu/HealthCareMBA
Representing the entire health care
sector, our students are experienced
industry professionals. They build a
foundation in business, critical thinking and leadership while developing
a deep understanding of the health
care industry.
Verge Solutions
Booth #314
P.O. Box 394
Mt. Pleasant, SC 29465
843-628-4168
[email protected]
www.verge-solutions.com
Verge Solutions offers SaaS solutions
to automate administrative processes.
Combining the collective wisdom of
our customers with software expertise,
we understand technology is key for
better outcomes and lower costs.
Platinum Sponsor
VHA
Booth #707
290 East John Carpenter Freeway
Irving, Texas 75062
972-830-0000
[email protected]
www.vha.com
VHA is a national network of not-forprofit health care organizations that
work together to set new levels of
clinical performance, establish best
practices to improve operational
efficiency, and gain maximum
savings in the supply chain arena.
25th Annual National Forum on Quality Improvement in Health Care
VigiLanz Corporation
Vocera
Booth #1206
Booth #712
VigiLanz real-time software-as-aservice surveillance solutions for
infection control, pharmacy, and
quality programs enable expedited
NHSN submission, HAI tracking,
robust analysis, reports, and
antimicrobial stewardship, optimizing
clinical outcomes and efficiencies.
Virginia Mason Institute
Booth #1436
1100 Olive Way Suite 501
Seattle, WA 98101
206-341-1600
[email protected]
www.virginiaMasonInstitute.org
Experience-based learning in the
Virginia Mason Production System
(VMPS). Meet our faculty to learn how
your organization can: Improve quality
and safety for patients, eliminate
waste, and improve staff satisfaction.
Vocera provides innovative care
experience solutions that restore the
human connection in care, resulting
in better care team communication,
improved patient satisfaction and
safety, reduced readmission rates,
and market differentiation.
Booth #501
10880 Wilshire Blvd. Suite 300
Los Angeles, CA 90024
310-954-1950
[email protected]
www.zynxhealth.com
New Exhibitor
525 Race Street
San Jose, CA 95126
800-331-6356
[email protected]
www.vocera.com
Zynx Health
Vree Health
Booth #1214
351 N Sumneytown Pike
North Wales, PA 19454
267-305-2507
[email protected]
www.vreehealth.com
Zynx Health, subsidiary of
Hearst Corporation, is the
market leader in providing
evidence-based clinical
decision support solutions that
help health care organizations
measurably improve patient
outcomes, enhance safety, and
lower costs.
EXHIBITORS
5775 Wayzata Boulevard,
Suite 970
Minneapolis, MN 55416
855-525-9078
[email protected]
www.vigilanzcorp.com
Platinum Sponsor
Vree Health is a wholly-owned
subsidiary of Merck.arge service,
TransitionAdvantage™, combines
innovative technology and personal
patito help coordinate care and
reduce readmissions.
International Forum on Quality
and Safety in Healthcare
8 - 11 April 2014, Paris
Improve quality. Reduce costs.
Save lives.
Book now and save up to £247
Early Bird ends 31 January 2014
Attend the 19th Annual International Forum:
• Be inspired by the international improvement community
with representatives from over 80 countries.
• Expand your network, learn and gather new practical ideas
for your quality improvement and patient safety initiatives.
The 2013 Forum sold out early. Reserve your place now at:
internationalforum.bmj.com
North Shore-LIJ Health System
is Committed to Providing the
Safest, Highest Quality Care to
the Communities We Serve
Building on our partnerships with IHI and other leading organizations to innovate
and transform healthcare for the future, North Shore-LIJ continues to focus on:
• Ensuring value by delivering high quality, reliable and efficient care
• Eliminating the incidence of healthcare-acquired conditions
• Early sepsis diagnosis and treatment resulting in reduced mortality
• Improving care for patients with advanced illness
• Educating the next generation of physicians and healthcare professionals
To learn more, visit us at
Booth #507 in the Exhibit Hall
or online at northshorelij.com.
70
Thank You
TO OUR CHAIRS
acknowledgements
Acknowledgements
IHI would like to thank the National Forum co-chairs for their extraordinary effort and commitment
in developing the program for the 2013 National Forum:
Mark Smith, MD, MBA,
President and CEO, California Healthcare Foundation
Michael Dowling,
President and CEO, North Shore-LIJ
Christian Farman,
Registered Nurse, Ryhov County Hospital
Molly Joel Coye, MD, MPH,
Chief Innovation Officer, UCLA Health System,
Institute for Innovation in Health
All planning committee members and persons influencing the content of the National Forum program have disclosed
all relevant financial relationships with any commercial interest to the Institute for Healthcare Improvement.
IHI would like to thank our board of directors
For their ongoing support and guidance
James M. Anderson,
Advisor to the President
Cincinnati Children’s
Hospital Medical Center
Cincinnati, OH
A. Blanton Godfrey, PhD
Dean and Professor
College of Textiles
North Carolina State University
Raleigh, NC
Arnold Milstein, MD, MPH
Medical Director
Pacific Business Group
on Health
San Francisco, CA​
Maureen Bisognano
President and CEO
Institute for Healthcare
Improvement
Cambridge, MA
Jennie Chin Hansen
CEO
American Geriatrics Society
New York, NY
Dennis S. O’Leary, MD
President Emeritus
The Joint Commission
Oakbrook Terrace, IL
Helen Haskell
Founder and President
Mothers Against Medical Error
(MAME)
Columbia, SC
Rudolph F. Pierce, Esq.
Attorney (Of Counsel)
Goulston & Storrs, PC
Washington, DC
Michael Dowling
President and CEO
North Shore – LIJ
Great Neck, NY
Elliott S. Fisher, MD, MPH
Director for Population Health
and Policy
The Dartmouth Institute
for Health Policy and
Clinical Practice
Lebanon, NH
Terry Fulmer, PhD, RN, FAAN
Dean, Bouvé College of
Health Sciences
Northeastern University
Boston, MA ​
Brent C. James, MD, MStat
Chief Quality Officer
Executive Director, Institute for
Healthcare Delivery Research
Intermountain Healthcare
Salt Lake City, UT
Gary S. Kaplan, MD
Chairman & CEO
Virginia Mason Medical Center
Seattle, WA
25th Annual National Forum on Quality Improvement in Health Care
Nancy L. Snyderman, MD, FACS
Chief Medical Editor, NBC News
Associate Professor of
Otolaryngology, University
of Pennsylvania
New York, NY
Diana Chapman Walsh, MS, PhD
President Emerita
Wellesley College
Wellesley, MA
71
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It only does everything.
™
Your Quality
Department
doesn’t have to
go it alone!
Join Passport and receive a comprehensive set of
online tools to accelerate your improvement efforts
and engage staff at your hospital.
The exclusive benefits of a yearlong membership for $5,000 include:
• Unlimited participation in Expeditions—two-to-four month, web-based programs led by
expert faculty and designed to address your organization’s highest improvement priorities
• Registration for Leading Quality Improvement: Essentials for Managers—a three-month
virtual program designed to teach your middle managers the skills they need to lead
improvement at your organization
• A 25% IHI Open School online course subscription discount
• Other tools, including on-demand podcasts, videos, and presentation materials
Join the hundreds of other Passport members—become a member today!
Learn more, and network with existing members, at the Special Interest Breakfast:
Wednesday, December 11th
7:00 AM – 7:45 AM
Anaheim
73
Mark your calendar for next year’s
26th Annual National Forum
on Quality Improvement in Health Care:
December 7–10, 2014
ORLANDO, FL
Stay connected with IHI and your fellow National Forum
attendees until next December! Follow us on Twitter, Facebook, and LinkedIn
to stay updated on all the National Forum news.
FACEBOOK
LINKEDIN
TWITTER
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It’s easy to achieve all your quality improvement goals when you analyze your data with Minitab 16.
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Minitab Inc. provides exceptional sales, technical support and training for Minitab 16.
For more information, visit www.minitab.com
75
N
O
R
T
H
W
E
S
T
E
R
N
U
N
I
V
E
R
S
I
T
Y
The Time is Now.
Take the Lead.
PROGRAM DIRECTORS:
Kevin Weiss, MD, MPH
Professor of Clinical Medicine
Feinberg School of Medicine
Northwestern University
Donna Woods, EdM, PhD
Associate Professor
Feinberg School of Medicine
Northwestern University
Graduate Programs in
Healthcare Quality and Patient Safety
•MasterofSciencedegreeinHealthcareQualityandPatientSafety
A two-year, part-time degree program which focuses on the knowledge, skills, and
methods necesary for improving healthcare delivery systems. It is designed for
both clinical and non-clinical professionals currently working in the healthcare
setting who want to focus their career development on these important areas
GUEST FACULTY INCLUDE:
James Bagian, MD, PE
in healthcare.
Engineer and former
NASA Astronaut
•FacultyDevelopmentPrograminHealthcareQualityandPatientSafety
James Battles, PhD
tools, methods, and curricular approaches for integrating healthcare quality
Agency for Healthcare Research
& Quality (AHRQ)
Carmella Bocchino, RN, MBA
America’s Health Insurance Plans
Helen Burstin, MD, MPH
National Quality Forum
A one-year program designed for faculty who wish to develop the educational
and patient safety into the medical education curriculum.
•CertificatePrograminHealthcareQualityandPatientSafety
A one-year program designed for the learner who wants to acquire a
comprehensive overview of these fields.
John Gosbee, MD, MS
Human Factors Engineering
& Healthcare Specialist
Martin Hatlie, JD
Partnership for Patient Safety
The above programs are all part-time and do not require Chicago residence.
Students are required to travel to our Chicago campus for a series of
classroom-based intensive sessions. Accommodation is available at select
local area hotels at a reduced rate.
Karen Kmetik, PhD
American Medical Association
Julie Johnson, MSPH, PhD
For more information, please contact
University of New South Wales
Meetal Acharya at [email protected]
L. Gregory Pawlson, MD, MPH
or by phone at 312-503-5533.
Derek Robinson, MD, MBA
Please visit our website at:
American Hospital Association
www.northwestern.edu/quality-safety
Kathleen Sutcliffe, PhD, MSN
University of Michigan
Ross School of Business
Robert Wears, MD, MS, PhD
University of Florida
and Imperial College London
United Airlines Corporate
Safety Team
76
“The need for leadership in health care has never been greater…”
25th Annual National Forum
Improvement
intheHealth
Care
— fromon
The Quality
Institute of Medicine
report, Crossing
Quality Chasm
77
25th Annual National Forum on Quality Improvement in Health Care
AND
CONGRATULATIONS
THANK YOU
Institute for Healthcare Improvement for your 25 years
of improving health care; and for your continued
commitment to support health care professionals.
Visit Edwards Lifesciences, booth #1007, to learn how you can
standardize care to reduce post-surgical complications.
Edwards, Edwards Lifesciences, and the stylized E logo are trademarks of Edwards Lifesciences Corporation.
© 2013 Edwards Lifesciences Corporation.
All rights reserved. 0005-CC-11.12
Edwards Lifesciences | edwards.com
Irvine, California 92614 USA
Congratulations to the
Institute for Healthcare Improvement
on the
25th Anniversary of the IHI National Forum
The more than 46,000 team members of North Shore-LIJ Health System are proud of
our collaboration with IHI on initiatives to improve healthcare quality and patient safety.
We look forward to working together for many more years to improve the health of
people around the globe.
Michael J. Dowling
President and CEO
North Shore-LIJ Health System
Great Neck, New York
Chair, IHI Forum 2013
Secretary-Treasurer, IHI Board
17425 IHI Forum 25th Anniversary Guide 13 Ad: 8x5
79
Join IHI and over 1,000 engaged improvers
as we harness the power of collaboration and
set bold ideas in motion.
Reserve your spot at the 15th Annual Summit on Improving Patient Care in the
Office Practice and the Community, and be part of a dynamic gathering of your
colleagues and thought-leaders from around the globe.
Over the course of three days and more than 60 sessions, we’ll explore cutting-edge
improvements for office practices, outpatient settings, and communities. As the tides
change once again in health care, we’ll seek out new ways to create a culture of
continuous improvement, engage patients and communities in redesigning care,
and chart a bold new course for the future.
This year’s keynote speakers are not to be missed:
• Laura Adams, President and CEO, Rhode Island Quality Institute
• Derek Feeley, Executive Vice President, IHI
• Ed Wagner, MD, MPH, Director, Group Health Cooperative
Enroll today! ihi.org/ihisummit
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81