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Collaborative Learning Sessions

Stratis Health Resident and Patient Safety Outcomes Congress

May 11, 2011

This culminating event for the Resident and Patient Safety Collaborative brought together nursing home and hospitals that worked to improve specific patient safety initiatives. This collaborative, which began August 1, 2008, will run until the end of July. Attendees to this outcomes congress came together to celebrate the great improvements made over the past three years by hospitals and nursing homes that participated in the collaborative.

Objectives

  • Discuss state and national initiatives that may affect nursing home/hospital quality improvement and safety.
  • Use lessons learned and best-practices from nursing homes/ hospitals that applied quality improvement and culture change strategies to improve the lives of those they serve.
  • Describe how eHealth can help strengthen local health care organizations and systems and support improved care delivery in the future.

Handouts

Agenda


Welcome

Breakout session 1a Pressure Ulcer Reduction

Braden Assessment

Nutritional Assessment

Skin Evaluation

Skin Tears

Skin Bruise Log

Tissue Tolerance Assessment-Lying

Tissue Tolerance Assessment-Sitting

Admission Body Check

Wound Note

Wound Record


Breakout session 1b Organizational Patient Safety Culture

It’s OK Poster

Interdepartmental communication

SBAR Notepad

SBAR Reporting

Breakout session 2a Reducing Personal Alarm Use


Breakout session 2b Improving Surgical Care

Venous Risk Factor

Health Information Technology: Progress, Expectations, Resources

Where Are We Headed?

Success Story Booklet

Learning Session #3

May 6, 2010

Plenary sessions focused on leadership and its role in driving and sustaining change, personal stories of leading change, and a practical session on executive rounding. Breakout sessions will focus on specific topics for nursing homes and hospitals – acting on AHRQ Patient Safety results, “Behavioral Challenges and Dementia: The Importance of Communication”, action planning, and “The Skin Care Fair” (a fun, interactive educational session for nursing assistants to prevent pressure ulcers, presented in "Train the Trainer" format).

Objectives

  • Discover and build a network of peer relationships to facilitate sharing ideas and best practices to drive improvement.
  • Describe common challenges that arise when leading change and how to overcome them.
  • Describe how to apply strategies for sustaining change in an organization.

Handouts

Welcome

Keynote: Driving and Sustaining Change

Breakout session 1a Skin Care Fair

Breakout session 1b Root Cause Analysis

Front Line Manager's Approach to Change

Breakout session 2a Acting on AHRQ and Patient Safety Culture Survey Results

Breakout session 2b Communicating Through the Stages of Dementia

A Leaders Personal Story: Perham Memorial Home

Promoting Skin Integrity: Pressure Ulcer Prevention Hospital and Nursing Home Focus

December 8, 2009

Objectives

  • Recognize the impact a pressure ulcer has on the person, their overall health and well being.
  • Describe key components of a comprehensive skin integrity program.
  • Share with your facility:
    • Two practical strategies for implementing a pressure ulcer prevention program.
    • One idea for monitoring your pressure ulcer prevention program to ensure it stays on track
  • Identify three resources for up-to-date pressure ulcer prevention and treatment strategies

Handouts

Agenda

Welcome

Pressure Ulcer Prevention - Part I Comprehensive Skin Integrity Program

Pressure Ulcer Prevention: Implementation Strategies

Successful Transitions within your setting and across settings

Creating Successful Outcomes

Barrier issues and strategy summary

Learning Session #2

October 28, 2009

The day-long workshop will include sessions on “Just Culture,” reduction of physical restraint use, and the TeamSTEPPS model – all with the common link to resident and patient safety and quality. 

Objectives

  • Identify networks and be able to share ideas and best practice with other providers.
  • Describe the philosophy, principles, and application of a “Just Culture.”
  • Explore a holistic and interdisciplinary approach to reducing physical restraints.
  • Describe and apply the essential components of the TeamSTEPPS model to improve communication and teamwork within your organization and across care settings.
  • Identify safety strategies that will improve safety in the care setting.

Handouts

Agenda

Welcome

"Just Culture"

Breakout session 1a Creating Home, Would you do this at home? (note: Joanne Rader presented Breakout session 1a, 2a, and 3a as concurrent sessions. The slides posted here are her entire presentation.)

 

"The Four Roles for Problem Solving" Chart

"Where are you on the culture change continuum" Worksheet

Culture Change Continuum

"Use of Alarms as Restraints" Position Paper

Care Planning Case Studies

Facilitating a Learning Circle

Breakout session 1b Just Culture: Case Studies

Just Culture: Case Studies Answers

Breakout session 2a Moving from provider-directed to person-directed care:  Where are you? (see note above)

Breakout session 2b TeamSTEPPS

Breakout session 3a Creating Home: Creating a plan of care that is practical and realistic and modifies risk (see note above)

Breakout session 3b Stories from the field: experiences implementing safety strategies

 

Life Care: Presentation, Learning from Defects Tool

Tri-County Hospital: Presentation, Pre-Op orders, Hand-off communications worksheet, Interdepartmental Communication Form

Grand Itasca Clinic and Hospital: Presentation, Transport passport, Patient Transport Summary, Physician Communication Protocol, Handoff Communication P&P, Procedural Surgical Safety Checklist, Report Tool

Next Steps/Closing

Learning Session #1

March 26, 2009


Stratis Health hosted a learning collaborative workshop for Minnesota hospitals and nursing homes participating in Stratis Health’s patient/resident safety work.

The day-long workshop included plenary sessions focusing on creating and sustaining a culture of safety and quality and working toward patient/resident partnerships to improve communication among caregivers and families, as well as break-out sessions focused on specific topics for nursing homes and hospitals: 1) pressure ulcer treatment and prevention; 2) interpretation of AHRQ staff surveys; 3) clinical perspective on surgical care improvement and methicillin-resistant staphylococcus aureus (MRSA); and 4) person-directed care.

Objectives

  • Describe how the CMS National Patient Safety Initiative will help participating Minnesota providers improve patient and resident safety culture in their organizations.
  • Apply evidence-based practices to improve care on a variety of clinical topics, i.e., surgical care, pressure ulcers, person-directed care, and MRSA.
  • Learn how the Agency for Healthcare Research and Quality (AHRQ) patient/resident safety culture survey can be used to improve the patient/resident environment.
  • Understand the TeamSTEPPS model for improved communication and teamwork to enhance patient/resident safety both within your organization and when coordinating care across settings.

Handouts

Agenda

Welcome

"Patient Safety, A Call to Action"

Breakout session 1a "Interpreting AHRQ Hospital Survey on Patient Safety Results and Action Planning

HSOPS Benchmarking Tool

Unsafe Acts Algorithm

Interpreting HSOPS Results

Breakout session 1b "Holistic Approach to Transformational Care"

Breakout session 2a Surgical Site Infection Project (SCIP)

SCIP Hospitals with Protocols in Place

31110 Order Set

31200 Order Set

Surgical Checklist

Orthopedic Post-Op Orders

VTE Risk Factors

Physician Orders

Preprinted Orders for VTE/DVT

Breakout session 2b "Pressure Ulcers--Hospitals and Nursing Homes"

Breakout session 3a "Methicillin-resistant Staphylococcus aureus (MRSA)

MRSA Surveillance

Breakout session 3b "Interpreting AHRQ Nursing Home Culture Survey (NHSOPS) to Improve Resident Safety in Nursing Homes"

NHSOPS Preliminary Results 2008

"Role of Teamwork in Patient Safety"

Next Steps worksheet