Southern California Patient Safety Collaborative

01-28-2010- Colloquium Agenda

Colloquium Evaluation

Track #1 - General Patient Safety
• Hospital Systems Load and Patient Safety
  Alberta Pedroja, Ph.D., Senior Consultant, ATP Healthcare Services, Northridge
• Transforming the Culture of Safety: Journey to Perfect Care
  Mary Ann Vincent, MBA, RN; Ray Casciari, MD; & Tina Retrosi, RN, St. Joseph Hospital
• Creating High Reliability with Crew Resource Management & Avoiding Normalization of Deviance
  David Marshall, CEO, Safer Healthcare

Track #2 - Medication Safety
• Antimicrobial Stewardship: Is it Possible in our Hospital?
  Silvia I. Gnass, Director of Infection Prevention & Control, Riverside County Regional Medical Center
• Pharmacist in the Emergency Department
  Valena Emery, RHIA, CPHQ, HACP, Director of Organizational Performance, Glendale Adventist Medical Center
• Three Safety Tools: Smart Infusion Devices, Dispensing Robot & Clinical Information
  Kathy Harren, CNO; Muno Bholat, Pharm.D.; & Mark Umekubo, Pharm. D.,Providence Little Company of Mary Medical Center, Torrance

Track #3 - Focus on Patients
• Memorial Care: Our Journey to Patient & Family-Centered Care
  Rita Goshert, MS, CCLS, Libby Hoy, BS, Memorial Care
• Serious Events: The Consumer Experience
  Sanjaya Kumar, MD, CEO Quantros; Dan Ford, Vice President, The Furst Group; and Liz Augusta, Patient Safety & Quality Consultant, L.A. County Health Services
• Implementing a Successful Sepsis Program
  Cynthia Coleman, BSN, RN, CCRN, Clinical Sepsis Coordinator, Charleston Area Medical Center, Charleston, WV

Track #4 - Safety Tools
• WHO Surgical Safety Checklist
  Yasmin Shikina, RN; and Claudett Dorsey, RN,Providence Little Company of Mary Medical Center, Torrance
• The Mini-Root Cause Analysis Tool: Getting to the Root of Falls
  Norma McNair, PhD(c), RN; & Catherine Walsh, MSN, RN,Ronald Regan UCLA Medical Center
• Post fall huddle
  
• Improving Patient Safety with the Baldridge Framework
  Paul Green, MS, RN, CPHQ,Chief Quality Officer, Memorial Hospital of Gardena

Track #5 - Perinatal Safety
• Overcoming the Top 10 Risks in Perinatal Patient Care
  Kaye Blom, BSN, RN, EJD, CLNC, CPHRM, The Risk Management and Patient Safety Institute
• Reducing Hospital Acquired Infections in the NICU
  Jil Lehr, MSN, RNC, CNS, & Lisa Lima, MSN, PNP, CNS, NICU, St. John’s Regional Medical Center
• Using Collaborative Approach to Improve Perinatal Safety
  Maureen Archambault, VP, Marsh Risk & Insurance Services; Heather Gocke, Risk Management Director, Beta Healthcare Group; and Annie Herlick, VP, Beta Healthcare Group

Track #6 - Focus on Nursing
• Leveraging CIS to Improve Nurse-Sensitive Patient Outcomes
  Gwen Matthews, CNO; Sharon Price, CIS Coordinator; Emillie Battig, CIS Educator; Katy Lancaster, Skin PI team chair, Glendale Adventist Medical Center
• Using Collaborative Case Management, RM & CDM to Mitigate Future Financial Risks
  Bill Hammock, BSN, RN, CMC, ACM, CPHQ, & Stacy Donegan, CPC, Marsh’s Global Clinical Healthcare Consulting Practice
• CalNOC: Understanding Medication Administration Processes and Outcomes
  Mary Foley, PhD(c), MS, RN,University of California,San Francisco

12-15-2009 Track II Meeting Agenda

December 15, 2009 Event Evaluation Link

Wasted Effort: Backsliding After Improvement –
How to Hardwire Sustainability Into Your Project- Redwood
Bruce Spurlock, MD, Convergence Health Consulting

Results of AHRQ Hospital Surveys on Patient Safety; A Systems Experience- Redwood
Presented By Memorial Care

SCPSC Data Results
Bruce Spurlock, MD, Convergence Health Consulting

Breakout Sessions

Charisse Cassell, Quality Improvement Specialist, Health Services Advisory Group

Mary Ransbury, Corporate Director of Wound/Skin Management, Prime Healthcare, West Anaheim Medical Center

Nancy Pratt, Sr. Vice President Clinical Effectiveness, Sharp Healthcare, and the San Diego Patient Safety Council
Tool Kit PCA

Microbial Biofilms: Unlocking the Mysteries Behind Infections
Marcia Ryder, PhD, MS, RN Independent Researcher, sponsored by Sage

Evaluation Link

11-10-2009 Track I Meeting Agenda

Prevention of Surgical Site Infection
Kamal Itani, M.D. Chief of Surgical Service, VA Boston Medical Center; Professor of Surgery, Boston University and Harvard Medical School, Boston, MA

Biography on Kamal M. Itani, M.D.

Sustainability and Sepsis
Bruce Spurlock, MD, Convergence Health Consulting

Interactive Breakout Sessions

Peggy Cusack, Nursing Director of Critical Care Services, Pomona Valley Hospital Medical Center

Speaker :Patsy Jones, MN, Director of Patient Safety, Health Services Advisory Group

Speaker: Howard Pitluk, MD, MPH, FACS, Health Services Advisory Group

Hospital Leadership Quality Assessment Tool
Andrea Silvey ,PhD, MSN, Chief Quality Improvement Officer,
Health Services Advisory Group

09-02-2009 Track II Meeting Agenda

09-02-2009 Track II Meeting Evaluations

Pressure Ulcers Care: Hospital Actions for Improvement
Barbara Bates-Jensen, PhD, RN, Associate Professor UCLA School of Nursing and
David Geffen School of Medicine

Hospital Leadership Quality Assessment Tool
Andrea Silvey , PhD, MSN, Chief Quality Improvement Officer, Health Services Advisory Group
HSOPSC Brief Overview

Interactive Breakout Sessions

• Presenter: Deborah Zaricor, RN, WOCN, Good Samaritan Hospital

Medication Administration Processes and Outcomes

• Presenter: Mary E. Foley, RN, MS PhD, Associate Director, Center for Nursing Research and Innovation University of California San Francisco School of Nursing & CALNOC Team Member

• Presenter: Suzanne R. Anders, MHI, RN, CPHQ, Clinical Quality Specialist,
Health Services Advisory Group
(Note: Handouts for the Team STEPPS presentation will be provided at the meeting)

Patient Safety Culture: Building the Patient-Centered Team
Deane L. Wolcott, MD, Vice President, Clinical Program Development, Aptium Oncology

Hospital Survey on Patient Safety Culture
Andrea Silvey ,PhD, MSN, Chief Quality Improvement Officer, Health Services Advisory Group

08-04-2009 Track I Meeting Agenda

08-04-2009 Evaluation

A Rapid Response Team Approach to Sepsis
Frank Sebat, MS, MD, FCCP, FCCM, Feather River Critical Care Medical Group

• A Systems Approach To The Early Recognition....In Sepssis and Septic Shock

Use of Simulation to Improve Sepsis Treatment
Laurie Jensen, RN, BSN, Clinical Development Specialist, Medical Simulation Corporation
Interactive Breakout Sessions

• A SCIP Success Story
• Earl Strum, MD, Chief of Anesthesia, USC University Hospital


• MRSA
• Sue Chen, RN, MPH, CIC, Infection Preventionist/ Health Associated Infection Program Coordinator, California Department of Public Health


• Central Line Blood Stream Infections
• Annemarie Flood, RN, BSN, CIC, Infection Control, Program Coordinator, City of Hope


• Patient Safety Culture: Building the Patient-Centered Team
• Deane L. Wolcott, MD, Vice President, Clinical Program Development Aptium Oncology


• Hospital Survey on Patient Safety Culture
• Andrea Silvey, PhD, MSN, Health Services Advisory Group
• Feed Back Report Sample

2009 SCPSC Data Submission Presentation

07-31-2009 Hop on Bus Webinar- PDF Presentation

06-16-2009 Track II Meeting Agenda

6-16-2009 Meeting Evaluations

Evidence Based Pressure Ulcer Prevention: Gaps in Implementation
Nancy Stotts, RN, Ed.D., FAAN, Department of Physiological Nursing,
University of California San Francisco

Panel Presentation : Antimicrobial Stewardship (for SCIP and for C.Diff)
Michelle Lee, Pharm.D., Methodist Hospital of Southern California
Carla Higbee, RN, MSN, FNP, California Hospital Medical Center
Richard Nelson, Pham.D., Eisenhower Medical Center

Interactive Breakout Sessions

• Reducing Hospital Acquired Pressure Ulcers with Skinsatinal Team
• Sandi Look, RN, BSN, Providence Little Company of Mary Hospital - Torrance


• High Alert Medications
• Donna Luong, Pharm.D., Medication Safety Coordinator,
  Cedars-Sinai Medical Center


• Preventing Hospital Acquired Clostridium difficile – Congressional
• Paul D. Holtom, MD, Hospital Epidemiologist, P&T Committee Chair,
• USC University Hospital
• Amy Basconcillo, Infection Control Practitioner, USC University Hospital

Standardizing Handoff Communication
Peter Kraslawsky, Account Executive, The White Stone Group

What Can You Do By Next Tuesday?
Mary Fermazin, MD, MPA, Health Services Advisory Group
Bruce Spurlock, MD, Convergence Health Consulting

• Plan-Do-Study-Act Worksheet
• Plan-Do-Study-Act Worksheet Sample

Memo from Mark Gamble, HASC Vice President to SCPSC Meeting Registrants.

05-07-2009 Track I Agenda

05-07-2009 Meeting Evaluation

MRSA and SCIP Updates
Dale W. Bratzler, DO, MPA, Oklahoma Foundation for Medical Quality

• SCIP-Inf-9 Measure Information Form
• SCIP-Inf-10 Measure Information Form

VTE Quality Measures and Medical Thrombo-prophylaxis
T. Brian Callister, MD, Internal Medicine Hospitalist, Reno, Nevada
David Patterson, MD, Medical Directorr, Casa Colina Hospital, Pomona

Interactive Breakout Sessions

Sepsis
Pat Lucken, RN, MSN, Director of Cardiac Service Line, St. Mary Medical Center

VTE – Tipping Point: How To Incorporate The Medical Evidence Into Practice
Tony J. Casanova, Pharm.D, St. Joseph Medical Center, Tacoma, Washington

• Physician Order Form-General Med Admission
• Physician Order Form-Total Joint Replacement
• OutPatient DVT Treatment Form
• Physician Order Form-VTE Prophylaxis for Oncology

Central Line Blood Stream Infections

Rebecca Berberian, White Memorial Medical Center
Edna DeLeon, Huntington Memorial Medical Center

• Central Line Flowchart
  
• Line Care

Systematic Care for Sepsis and Shock
Bryant Nguyen, MD, MS, Loma Linda University Medical Center

• Sepsis Bibliography
  

What Can You Do by Next Tuesday? – Colonial A&B
Mary Fermazin, MD, MPA Health Services Advisory Group
Bruce Spurlock, MD, Convergence Health Consulting

• Plan-Do-Study-Act Worksheet
• Plan-Do-Study-Act Worksheet Sample

Please Note: VTE Quality Measures and Medical Thrombo-prophylaxis Presentation & VTE – Tipping Point Presentation are not available for printing.

05-04-2009 Data Collection Webinar -2009

04-14-2009 TeamSTEPPS Webinar – PDF Presentation

04-14-2009 TeamSTEPPS Webinar – Audio Version

03- 04-2009 Track II Agenda

Meeting Evaluation

Overview of Track II Topics: Hospital Acquired Pressure Ulcers, High Alert Medications, Medication Safety, and Clostridium difficile.

• HAC in IPPS
• POA in IPPS

Bruce Spurlock, MD, Convergence Health Consultants

Hospital Acquired Pressure Ulcers: Prevention, Staging, and Documentation
Barbara Bates-Jensen, PhD, RN, Associate Professor UCLA School of Nursing and David Geffen School of Medicine

Interactive Breakout Sessions

• Preventing Pressure Ulcers

Melinda Jordan, RN, Ass’t Director, Hoag Memorial Hospital Presbyterian
Molly Hewett, Rn, Ass’t V.P., Hoag Memorial Hospital Presbyterian
Melinda Wertz, RN, Manager, Skilled Nursing, White Memorial Medical
Jasper Diaz, RN, Wound Care Specialist, White Memorial Medical Center

• Improving the safety of High Risk Medications

Lee Klevens, Pharm.D, Director of Pharmacy Services, Riverside County Regional Medical Center and Clinics

• VAD Flushing Survey
MERP Survey Preparation Tips
Catherine Carson, BSN, MPA, CPHQ, Hospital Association of Southern California

• Survey Process for Medication Error Reduction Plans (MERP)
  
• CDPH : Hospital Oversight

• Preventing Hospital Acquired Clostridium difficle

Alfonso Torress-Cook, PhD, EPI, Pacific Hospital of Long Beach
Antibiotic Safety Brochure

Diary of a Medication Safety Consultant – Colonial A&B
Dan Ross, Pharm.D., D Ross Consulting

02-3-2009- Track I Agenda

Track I Meeting Evaluation

Overview of Track I Topics: SCIP, MRSA, Sepsis, and CLBSI
Howard Pitluk, MD, MPH, FACS, Health Services Advisory Group
Bruce Spurlock, MD, Convergence Health Consulting

SCIP Measure Improvement
Clifford Ko, MD, UCLA School of Medicine

New California MRSA Active Surveillance Requirements
Dawn Terashita Gastelum, MD, MPH, LA County Department of Public Health

Implementing Sepsis Bundles
Edna DeLeon, Huntington Memorial Hospital

Hospital Survey on Patient Safety Culture
Andrea Silvey ,PhD, MSN, Health Services Advisory Group

Data Streams and 2009 AIM
Bruce Spurlock, MD, Convergence Health Consulting
Charlie Chapin, MS, CHCA, Health Services Advisory Group

2009 Southern California Patient Safety Collaborative.
HASC, HSAG, CHC, and NHF

SCPSC Colloquium Brochure

SCPSC Colloquium Evaluation

SCPSC Breakout Sessions

• Track #1- Mini Keynote
  

  California State Never 28 and Federal perspective on Hospital Acquired Conditions
  Mark Kadzielski, J.D., Fulbright and Jaworski

  A Pediatric Trigger Tool to Identify Adverse Drug Events
  Glenn Takata, M.D., MS and Carol Taketomo, Pharm.D., Children’s Hospital of Los Angeles

  The Journey to Clinical Excellence: Five Essential Strategies
  Samantha Collier, M.D., MBA, SVP & CMO, Health Grades

• Track # 2 - Team Work
  

  Pressure Ulcers: The Goal is Zero
  Joy L. Edvalson , MSN, FNP, CWOCN, West Los Angeles VA

  Condition H (HELP)
  Soudi Bogert, RN, BSN, clinical outcomes manager, Critical Care and Carmen Ferrell, RN, MSN, CCRN, executive director, Critical Care, St. Joseph Hospital

  Rapid Response Teams Run Don’t Walk
  Pat Lucken, RN, MSN, BC-NP, CPHQ, St. Mary Medical Center, Apple Valley, CA

• Track # 3 -Hospital Acquired Infections
  

  Zero Hospital Acquired MDROs: Starting a Journey
  Rekha Murthy, M.D., Hospital Epidemiologist, Cedars Sinai Medical Center

  I’ve Got You Under My Skin: Catheter‐Related Infections
  Ellen Jo Baron, Ph.D., director Clinical Microbiology Lab,Stanford University Med. Center

  No Mercy for MRSA
  Ellen Jo Baron, Ph.D., director Clinical Microbiology Lab, Stanford University Med. Center

• Track # 4 - Patient Safety
  

  What Can Aviation Teach Us About Patient Safety?
  Gregg Bendrick, M.D., CMO NASA, Dryden Flight Research Center

  Engaging Patient/Family Advisors to Achieve Perfect Care
  Maryann Vincent, RN, MBA and team, St.Joseph Hospital

  The Power of CHPSO in Improving Patient Safety in California Hospitals Rory Jaffe, M.D., MBA, executive director, California Hospital Patient Safety Organization

• Track # 5 - Improving Medication Safety
  

  KP MedRite – A Nurse Designed Medication Administration Innovation
  Dawn Fairbairn, RN, MHA and Melody Navarro, RN, MSN, Kaiser West Los Angeles

  Sedation and You: How to Avoid a Bad Outcome
  Stefanie Morrell, RRT, BS, CPHQ, director, Quality/Risk Services,St. Bernardine Medical Center

  Closing the Loop: Medication Management DeMystified
  Judi Binderman M.D., MBA, MHSA, consulting physician PrincipalCSC

• Track # 6 -Tomorrow’s Trends
  

  Transforming Quality & Safety by Creating a Learning Organization
  Steve Tremain, M.D., FACPE, senior medical director, Contra Costa Regional Medical Center

  The Influence of Volume and Systems Capacity on Patient Safety
  Alberta T. Pedroja, PH.D. senior consultant, ATP Healthcare Services Northridge

  Simulation and the Future of Quality Improvement
  Myrna Schnur, RN,MSN, healthcare product manager, Medical Simulation Corporation