Patient Safety session with Dr. James Bagian.
Hear from Pediatric Quality Award (PQA) semifinalists in the Clinical Care project category.
Hear how Pediatric Quality Award (PQA) semifinalists in the Delivery System Transformation category are meeting the challenges to transform both financing and service delivery.
Ann & Robert H. Lurie Children’s Hospital of Chicago and Children's Hospital of Pittsburgh of UPMC showcase strategies for transforming clinical care and data delivery. *VIDEO RECORDING AVAILABLE
Florida Hospital for Children and Riley Hospital for Children at Indiana University Health share workplace violence risk assessment and prevention tools.
By reviewing an emerging population health management program Children's Hospital of Philadelphia, attendees will receive concrete strategy and tools to support improvement approaches that can meaningfully impact the capacity management of Medicaid admissions at children's hospitals. Quality improvement and population-level data will be reviewed as evidence of impact.
Developed by the John Eisenberg Innovation in Patient Safety and Quality award recipients, this program is an evidence-based program to improve safety through family and inter-professional engagement in hospital communication. This session will address how to implement a nationally recognized Patient and Family Centered program to improve safety. *VIDEO RECORDING AVAILABLE
Undergoing surgery can be extremely distressing for children, but for those with autism spectrum disorder, the experience can be particularly traumatic, triggering fear and resistance, which can seriously disrupt the treatment process. By identifying children with special needs beforehand, a coordinated care team can create a significantly better experience for patients.
Children’s Hospital of Philadelphia describes their approach to engage patients and families as partners in improving appointment adherence and demonstrate how structured interviews and surveys determine barriers to adherence and reminder preferences. As a result, the hospital implemented a new reminder platform, which helps communicate with patients and backfill open slots.
The RN and M.D. quality and safety leadership dyad has rapidly decreased preventable patient harm by fusing the expertise of physicians and nurses. Discover how the leadership dyad led to hospital preventable harm events decreasing by 22 percent and hospital engagement scores related to quality and safety significantly improving.
Family engagement reduces length of stay in Neonatal Abstinence Syndrome patients and utilizing Trauma-Informed Care (TIC) at the bedside increases this familial engagement. Attendees will understand the history and importance underlying TIC, learn tools and strategies to implement TIC, and work through cases in small groups with expert guidance in applying TIC to real-life scenarios.
Advancing Patient Experience scores have traditionally focused solely on activities improving the overall hospital experience for patients and families. Focusing on problems when they happen can yield positive outcomes and impact scores. Training in service recovery, the process of making things right, empowers staff with tools to enhance the overall hospital experience despite difficult or negative circumstances.
This session details a pilot model of primary-care, specialty-care partnership care coordination implemented for rural or limited-English proficient medically complex children. Despite implementation challenges, evaluation indicates increased family satisfaction with cross-system communication, appointment coordination and receiving important care information. Significant decrease in specialty-care utilization could reflect improved coordination and self-management ability. *VIDEO RECORDING AVAILABLE
Children’s National Medical Center embarked on a directive from the hospital Board and leadership to double incident reports in the organization. This session describes the aim and key drivers, as well as the results of the initiative in more than doubling the incident reports to over 10,000 in a three-year time frame.
Hassenfeld Children’s Hospital at NYU Langone Medical Center successfully developed and deployed Learning Boards across all inpatient units to integrate numerous improvement and safety initiatives under the banner of High Reliability. They provide an interactive, transparent display of improvement project goals and outcomes, and incorporate teaching of Improvement Science methodology and Safety Behaviors and Tools.
Children’s Hospital of Wisconsin explains a methodology that uses a simple "red/yellow/green" approach to describe census and staffing within the hospital. See how data can direct patient flow, staffing and overall improvement in quality of care, as well as experience provided.
Nemours/Alfred I. duPont Hospital for Children developed an electronic medical record- based, specialty specific perioperative antibiotic order set in Epic® Optime combined with a dynamic reminder in Epic® Anesthesia and a daily management system. After implementation, the hospital improved perioperative antibiotic compliance from 90 percent to nearly 100 percent.
Sleep-related deaths account for a significant percentage of infant deaths in our county. A network of primary care clinics in high-risk neighborhoods provided an effective venue to address this urgent concern. A multi-disciplinary team was successful in addressing the problem using quality improvement tools and multiple interventions.
Studies have demonstrated accelerated deterioration of kidney function in pediatric renal patients due to hypertension. Universal recognition of childhood hypertension is hampered by the necessity of factoring gender, age and height to determine elevated blood pressure percentiles. The Surveillance Target Outpatient blood Pressure (STOP) tool aids identification of hypertensive patients.
Seattle Children's Hospital's analytic community collaborated to create a sepsis datamart that identifies Emergency Department patients that may potentially develop sepsis and track them through the encounter. The hospital tapped into the organization’s common safety culture and applied error prevention tools to validate the data and analytics by a multidisciplinary team. *VIDEO RECORDING AVAILABLE
High reliability organizations have common traits including: preoccupation with failure, sensitivity to operations, reluctance to simplify and commitment to resilience. Using these traits as key drivers, we aimed to develop a high reliability unit – a clinical microsystem with targeted outcomes related to patient safety, quality improvement and patient experience.
Disjointed data systems in the form of spreadsheets and ad hoc reporting, hinder hospitals from having dynamic discussion about hospital-acquired conditions (HACs). This session will demonstrate the transformation of managing HACs data, and how the changes made the data real-time and robust. The team accomplished the change using existing IT capabilities at zero cost.
The lack of signal elements between health care workers and users can generate errors caused by interruptions during drug administration depending on human, technical or environmental factors that can become a source of stress and adverse events. Identification and application of tools for the prevention of interruption promotes safety of drug administration.
This presentation will demonstrate the predictive validity and feasibility of the Acuity Tool developed to stratify patients by medical complexity while accounting for social, family, school, and behavioral variables. *VIDEO RECORDING AVAILABLE
Attendees will learn about the PHQ9 and CSSRS, which are scales used to screen patients for depression and suicidality in the Emergency Department. Rady Children’s Hospital staff will discuss their rollout of these tools and how the screenings have influenced care, including sitter allocation, safety precautions, and identifying patients at risk for depression and suicide.
Disparities in care related to patient characteristics such as race, ethnicity, gender and socioeconomic status can impact quality, safety, cost and risk management. Collaboration between quality improvement and medical ethics can support clinical teams during improvement efforts to identify and evaluate disparities in health care delivery and outcomes.
Fostering Team Work — Especially in Times of Crisis
Patient safety continues to be a major focus for children’s hospitals. Hear how the four semifinalists in the 2017 Pediatric Quality Award Patient Safety and the Reduction of Harm category significantly improved patient outcomes and made children’s health care safer.
Children’s hospitals are constantly challenged to reduce waste, improve efficiency and take costs out of the health care system, while improving clinical outcomes and patient satisfaction. Hear how these four semifinalists in the Waste Reduction/Improved Efficiency category achieve results.
Mayo Clinic Children’s Center and Nemours/Alfred I. duPont Hospital for Children use their experiences to deliver strategies for providing safe care to patients, families and staff.
Decreasing variation is central to optimizing outcomes and reducing waste and cost in health care delivery. This session describes a clinical effectiveness program leveraging personalized comparative effectiveness information at the point of care. The program provides target hospital goals for pediatric patients following surgery to reduce variability and promote high value care.
Elimination of hospital-acquired conditions improves patient safety. Timely information along with Clinical Process Review (CPR) can improve clinical care by elevating patient safety, increasing staff efficiency and reducing costs. The process of real-time data paired with CPR identifies issues and increases the ability to make immediate adjustments or improvements.
Designing a safety program begins with transforming safety culture throughout all levels of an organization, rather than starting with the program itself. This process requires the creation of an excellent, high-reliable safety culture framework to develop a program with measurable improvements in employee safety and processes.
Having a loved one in surgery can be stressful. Providing timely updates to families waiting during a procedure is important, but it may strain a surgical team’s resources. Nationwide Children’s Hospital implemented a mobile app to streamline the communication process for staff and improve family satisfaction.
To paraphrase the Institute of Medicine: humans err. How, then, do organizations prevent human error in complex environments? Hospitals implementing just cultures for safety have been successful, but there remains opportunity to further prevent patient harm through human factors engineering (HFE). In this session, learn more about how to apply HFE to harm prevention.
The Children’s Cancer and Blood Disorders Network (CCBDN) pioneered large-scale central line-associated bloodstream infection (CLABSI) prevention in pediatric hematology/oncology patients in both inpatient and ambulatory environments. This session reviews CCBDN’s innovative ambulatory work, teaches tools and approaches for outpatient CLABSI surveillance and prevention, and reviews current barriers to ambulatory infection prevention.
Challenges exist across organizations to effectively implement risk assessments. Children’s Mercy of Kansas City examines their foundation to operationalizing risk assessments to avoid pediatric harm. They will explain strategies to leverage existing organizational committees, involve key stakeholders, and apply tools to mitigate harm.
Behavioral economics (BE) is an interdisciplinary field commonly known for promoting positive outcomes in non-health domains, including retirement savings, school attendance and energy conservation. This educational session will highlight the following BE strategies for improving pediatric health care: accountable justifications, peer comparisons, salient images, framing, default setting and reciprocity.
Historically, organizations have judged effectiveness of medication reconciliation based on how often it was performed. While this is easy to track, it doesn't represent what is truly important to clinicians and patients. Seattle Children’s qualitative medication reconciliation analysis instead looks at the accuracy of the patient's discharge medication list.
To address the well-being of health care providers, Children’s Hospital Colorado implemented a comprehensive resiliency program. They created a Resiliency Collaborative that used interventions and validated measurement instruments that provide support and rationale for program growth.
Workplace violence is a recognized hazard in health care. While statistics show alarmingly high rates of violence, the numbers are likely even higher due to underreporting. This session will describe one institution’s journey to promote interprofessional awareness and skill acquisition to deal with disruptive behaviors displayed by patients and visitors.
Psychological safety around event reporting is a critical component of safety culture and the ability to voice concerns without reprisal leads to a safer environment. Using a multidisciplinary improvement model to improve event reporting led to quantitative gains in safety climate domain as measured on the Safety Attitudes Questionnaire culture survey.
An estimated 30 to 40 percent of youth living with chronic illnesses struggle with depression, anxiety and other mental health issues. Youth and family mental health needs are often under-identified and unmet within pediatric chronic illness care. Leveraging coproduction and improvement science, the team from Hassenfeld Children’s Hospital of New York at NYU Langone Medical Center will present an implementation guide to behavioral health integration.
Learn strategies for transforming clinical care and data delivery.
Learn about a tool developed to stratify patients by medical complexity while accounting for social, family, school and behavioral variables.
Learn about a pilot model of primary-care, specialty-care partnership care coordination implemented for rural or limited-English proficient medically complex children.
Learn how to implement a nationally recognized patient and family-centered program to improve safety.
Learn about creating a sepsis datamart that identifies emergency department patients that may potentially develop sepsis.
Efforts to engage front line staff members, patients and families can lead to a decrease in CLABSI rates.
How the original IPASS concept is being adapted and used as a way to engage patients and families and improve the quality of care.
Data plays a key role in helping this hospital document the treatment of sepsis patients.
Children's National Medical Center leadership saw opportunities to increase the number of safety events staff members report.
Leadership partnership has rapidly decreased preventable patient harm at Riley Children's by blending the expertise of physicians and nurses.
Rady Children's Hospital is screening all patients over the age of 12 in the emergency department.
Champions for Children's Health
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