SAVE THE DATE!
Next Conference: May 25, 2005

Call to Order
Sallie S. Cook, MD, President, VIPC&S
CMO, Virginia Health Quality Center

Plenary Session: Hospital Acquired Infections: An Appraisal of the Problem and a Glimpse at Solutions
David K. Warren, MD, Assistant Professor Of Medicine, Division of Infectious Diseases, Washington University School of Medicine; Hospital Epidemiologist, Barnes-Jewish Hospital

OBJECTIVE: At the conclusion of this session, the successful learner should provide an overview of the frequency of hospital-acquired infections, and the toll they exact on individual patients and the healthcare system. An introduction of evidence-based methods to prevent these infections will follow.

• Presentation

Plenary Session: Patient Safety Vignettes:  Merging New Technology with Vicariousness
Chuck Biddle, CRNA, PhD, Professor, VCU School of Allied Health Sciences, Department of Nurse Anesthesia

OBJECTIVE: This session will present short vignettes, reenacting actual patient care-related misadventures, and teach error avoidance skills that are grounded in an evidence-based approach. The successful learner will recall the genesis of error and its prevention by vicariously experiencing such events.

• Presentation
• Executive Summary

• Health Affairs: Federal Health Information Policy: A Case Of Arrested Development

• Presentation

Plenary Session: Embracing the Future: Deriving Value from IT: Designing For Quality and Patient Safety
Blackford Middleton, MD, Director of Clinical Informatics Research & Development, Partners Healthcare System

OBJECTIVE: At the conclusion of this session, the successful learner will describe the value of integrated clinical information systems, in particular electronic health records, and computerized provider order entry, in reducing medical errors and cost, and improving healthcare quality.

• Presentation

OBJECTIVE: This session will focus on more robust Fortune 500 strategies to direct their health benefits spending toward better performing hospitals and physicians. At the conclusion of this presentation, the successful learner will recognize that maximizing value for both the employer and employee is the goal and the chief challenges are (1) how best to measure what is considered ‘of value’ and (2) how to excel on the measures.

• Presentation

OBJECTIVE: This session is designed to explore methods of “building the case” for evidence-based interventions to prevent hospital-acquired infections with hospital administrators, and nursing and physician leadership. At the conclusion of this session, the successful learner will be able to select and measure meaningful outcomes for hospital stakeholders, and practical issues associated with the actual implementation of these programs.

• Presentation

Track II: MCV Fellows: Selected Patient Safety Programs

“Retrospective Review of Human Factors Associated with Adverse Events”
Teresa Blomberg, MS, RN, CPHQ, Patient Safety Officer & Risk Manager, VHA Rocky Mountain Network

OBJECTIVE:  To prevent future high-morbidity and fatal adverse events through identification of contributing factors of past events and implementation of interventions to prevent future, similar events. At the conclusion of this presentation, the successful learner will be able to:

• Review and collate RCAs (Root Cause Analysis) on adverse events by event category and contributing factors
• Identify possible systems changes based on the most frequently occurring factors
• Identify some of the difficulties of determining if systems changes from RCAs were fully implemented.
• Recommend systems changes to leadership based on frequently occurring human factors from RCAs.
• Presentation

“Evaluating the Use of a Trigger Tool to Monitor the Rate of Adverse Drug Events and the Effectiveness of System Improvements.”
Jane Dresselhaus, RN, MSN, Performance Improvement Coordinator, Bon Secours Mary Immaculate Hospital

OBJECTIVE:   This session will describe the results of a two year project which utilized a trigger tool to measure and improve Adverse Drug Events. This trigger tool methodology can be easily applied in any hospital setting regardless of computer support. It will also discuss the maturation of the trigger tool to detect a variety of adverse events as well as adverse drug events. At the conclusion of this presentation, the successful learner will be able to:

• Describe the development and use of a trigger to monitor Adverse Drug Events (ADE’s).
• Compare ADE’s which occurred in three hospitals with those found in the published literature.
• Describe improvement strategies utilized to decrease the occurrence of ADE’s in one community hospital.
• Discuss additional strategies available for automating capture of ADE’s.
• Describe the maturation of the ADE trigger tool into an adverse event trigger tool.
• Presentation

“Quality at the Crossroads - The Development of a Comprehensive Clinical Variance Reporting Program”
Rudolph Freeman JR., MD, Vice President of Medical Affairs
Riverside Health System

OBJECTIVE:  At the conclusion of this presentation, the successful learner will be able to:

• Identify opportunities for clinical integration of all quality assessment and performance improvement initiatives within the organization
• Define the infrastructural elements, organizational cultural readiness and commitment in developing a comprehensive clinical variance reporting process that will serve as the cornerstone for a comprehensive patient safety program
• Outline the process for successful implementation of a comprehensive clinical variance reporting program
• Outline the barriers in coordination, tracking and communication of all quality assurance and performance improvement activities
• Determination of a return on investment of organization’s quality initiatives
• Presentation

Track III: Preventing Misadventures in Patient Care: Vicarious Learning via Patient Safety Vignettes
Chuck Biddle, CRNA, PhD, Professor, VCU School of Allied Health Sciences, Department of Nurse Anesthesia
William Hartland, CRNA, PhD, Associate Professor, VCU School of Allied Health Sciences, Department of Nurse Anesthesia

OBJECTIVE: At the conclusion of this session, attendees will recall how multi-media interventions, based upon principles of adult learning and rounded in an evidence-based approach, can be employed in a variety of health care settings to promote patient safety and reduce the rate of care-related misadventure.

• Executive Summary

Track IV: "Promise, Perils and Performance of CPOE: CIO Roundtable" presented by the Virginia HIMSS Chapter
Introduced by David Collins, President, Virginia HIMSS Chapter
Moderator: Ramesh K. Shukla, Ph.D., Professor and Director, Williamson Institute for Healthcare Leadership, Department of Health Administration, Virginia Commonwealth University

• Randy Axelrod, MD, Vice President and General Manager, Anthem Blue Cross and Blue Shield
• Barbara Baldwin, Chief Information Officer, University of Virginia Medical Center
• Bert Reese, Chief Information Officer, Sentara Healthcare
• Laishy Williams-Carlson, Chief Information Officer, Bon Secours Hampton Roads

OBJECTIVE: At the end of conclusion of this panel discussion, the successful learner will be able to:

• Define CPOE and its basic components and differentiate CPOE from existing legacy systems in academic medical centers where the majority of medical orders are entered by physicians, residents, fellows and house staff
• Discuss social, political, and economic issues in adopting CPOE in community hospitals
• Describe technical transformation in the deployment of CPOE
• Discuss ROI propositions and models and differentiate between potential savings vs. Realizable savings vs. expected savings
• Discuss the processes of clinical transformation of healthcare delivery system using CPOE and its potential impact on hospitals, physicians, organization of physician practices, and physician performance.
• Baldwin Presentation
• Reese Presentation
• Shukla Presentation
• Williams-Carlson Presentation