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AGENDA: OPTIONAL PRECONFERENCE SYMPOSIUM
PATIENT SAFETY OFFICER TRAINING
Monday, August 18, 2008

Participation in the Preconference Symposium on Patient Safety Officer
training is mandatory for those in the Patient Safety Certificate Program.

11:00 a.m. Registration Commences at Annenberg Hall, Harvard University
Preconference Symposium Faculty:
  • Paul Barach, MD, MPH, Professor, Anesthesia and Emergency Medicine, Center for Patient Safety, Utrecht University Medical Center, and Associate Professor, University of South Florida, Utrecht, Netherlands (Co chair)
  • Julie K. Johnson, MSPH, PhD, Assistant Professor of Medicine, University of Chicago, Former Director of Research, American Board of Medical Specialties, Chicago, IL (Co chair)
  • Davis Balestracci, MS, Principal, Harmony Consulting, LLC, Portland, ME
  • Gwen Sherwood, PhD, RN, FAAN, Professor and Associate Dean for Academic Affairs, The University of North Carolina at Chapel Hill, School of Nursing, Chapel Hill, NC
Learning objectives:
The overall objective of the Pre-Conference Patient Safety Certificate Program is to start new and meaningful conversations about quality and safety - personally, in our organizations, and with our leaders.

Specifically we will:
  • Reflect on current levels of quality and safety in our organizations;
  • Change practitioners' everyday conversations about safety and the culture of safety;
  • Discuss how to engage the leadership in safety while changing their attitude toward safety.
1:00 p.m. Welcome and Introduction
Paul Barach
1:15 p.m. Mental Models and Framing of Safety and Quality
Julie Johnson
1:45 p.m. Small Group Discussion about the 5 Pre-Conference Questions Participants
  1. What are the most important patient safety issues facing your institution?
  2. How does the culture of your institution affect your ability to implement change?
  3. What are 3 patient safety initiatives that you've read about, heard about, or seen that you believe will make an impact in your institution?
  4. What are 3 patient safety initiatives you would like to implement in the next year?
  5. Describe the composition of the team that will be necessary to accomplish each of those initiatives in your institution.
2:00 p.m. Debriefing from Small Group Discussion
Gwen Sherwood
2:15 p.m. The Patient Safety Core Curriculum and Introduction to Lewis Blackman Story
Paul Barach
2:45 p.m. Small group discussion on Lewis' Story (a Pre-Analysis) Participants
3:15 p.m. Break
3:30 p.m. Data "Insanity": The silent improvement killer - Part 1
Davis Balestracci

Systems and Processes – The "assumptions" they never tell you about...that invalidate most of the statistics you've learned!
  • Process-oriented thinking1
  • Are you using special cause strategies?
  • "Plot the dots!" - Run charts and analysis2 (optional)3
  • What are the common cause strategies?4
  • What would you do with data like this now?5 (optional)
4:00 p.m. Group Discussion
Davis Balestracci
  1. How does your organization react to, report, and analyze "incidents?"
  2. Have you ever considered "safety" in a process-oriented context?
  3. Have you, with the best of intentions, been using "special cause" strategies? Could you "plot the dots" to see whether you have been successful?
  4. Does this material suggest situations in your organizations that might respond better to "common cause" strategies?
4:15 p.m. Engaging Leaders - From Turf Wars to Appreciative Inquiry, Principles of Leadership for Quality and Safety
Gwen Sherwood
4:30 p.m. Small Group Exercise
Gwen Sherwood
4:45 p.m. Debriefing from Small Group Exercise
5:00 p.m. Break
5:30 p.m. Data "Insanity": The silent improvement killer - Part 2
Davis Balestracci
  • Eradicating the myth of "trends"6 (optional)
  • Quick review of common cause strategy: Clearing up a common misconception3
  • "Owning" the "Learning and Growth" sub-business of your organization7
  • Statistics in a quality improvement perspective
6:00 p.m. Final discussion about the Lewis Blackman Story
What have we learned, how would we approach our analysis differently?
Facilitated Group Discussion (Topics to consider: disclosure, leadership, qualitative methods for learning about safety)
Paul Barach and Julie Johnson
6:15 p.m. Real World Dilemmas in Quality and Safety
  • What are the day-to-day issues that members of the audience face?
  • What are the strategies for addressing them?
  • Participants and Faculty
6:40 p.m. Concluding Comments, Questions and Post-Colloquium Examination Logistics
6:45 p.m. Adjournment




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